.GI_NORMAL

Skilled GI assessment: abdomen soft, non-distended, non-tender; bowel sounds normoactive ×4; no mass/guarding/rigidity/rebound; bowel pattern at baseline, last BM {when}; no nausea/vomiting; no bleeding signs; [ostomy stoma viable, output appropriate, skin intact]. RN judgment applied to screen for acute abdomen/bleeding and manage bowel/ostomy care given {dx}. Continued skilled monitoring indicated.

.GI_EXAM

Inspection {soft/distended}; bowel sounds {normoactive/hypo/hyper/absent} ×4; palpation {non-tender/tender/guarding/rigidity/rebound}; masses {y/n}; last BM {when}, Bristol {type}.

.GI_BLEED

Hematemesis {y/n}; coffee-ground emesis {y/n}; melena {y/n}; hematochezia {y/n}; pallor/hemodynamic change {y/n}; anticoagulation {y/n}; action {911/MD per order}.

.GI_OSTOMY

Stoma {beefy-red/dusky/retracted/prolapsed}; output {volume/character}; appliance {sealed/leaking}; peristomal skin {intact/breakdown}; teaching {appliance change}.

.GI_SKILL

Performed abdominal exam; screened acute abdomen/bleeding; managed bowel regimen {opioid-induced constipation}; ostomy care; coordinated {nausea/diet/hydration}; {escalated emergency}.

.GI_TEACH

Reviewed bowel regimen/constipation prevention, {ostomy care}, GI warning signs with {pt/cg}; method {teach-back/return-demo}; mastery {##}%.

.GI_COORD

Provider notified at {time} re {acute abdomen/bleeding/constipation/ostomy}; reported {content}; order received {regimen/evaluation}; {EMS activated}; reassessment {when}.

.GI_NECESSITY

Skilled nursing required today to {action} for {RN-level reason} given {dx}, resulting in {measurable effect}.