Assess GI status and document the skilled judgment:
Abdominal exam (distension, tenderness, bowel sounds), bowel pattern (last BM, consistency, continence), and any nausea/vomiting.
For a GI bleed: stool/emesis characteristics (melena, hematochezia, coffee-ground), vital-sign trend, and pallor; for a new ostomy: stoma color/viability, peristomal skin, output volume/character, and appliance seal.
Hydration status with severe diarrhea, isolation status for an infectious process (e.g., C. difficile), and the response to bowel-regimen or GI medications.
MDS-supportive data
Bowel continence and ostomy status are coded in MDS Section H; nutrition/feeding tube in Section K; IV medication and isolation in Section O; the GI diagnosis in Section I. The record must document the GI assessment, ostomy care, and any isolation so the MDS is supported.
