Ryder Practice For Serial Abdominal Exams In Trauma and Acute Care Surgery
Authors: Gabriel Ruiz – 5/1/23
Approval: Nicholas Namias – 5/1/23
Purpose
- Serial abdominal examinations must be documented.
Procedure
- The most senior housestaff member is responsible for assigning or performing and documenting abdominal examinations at an appropriate interval, but no less than every 12 hours.
- The examination should be documented in a progress note in the EMR. The note should record the physical examination of the abdomen, any changes from the previous examination, any changes in vital signs, and any requirements for analgesia.
- Any deteriorating exams must be discussed with the Chief Resident or Fellow, and the discussion must be documented.
Purpose
- Serial abdominal examinations must be documented.
Procedure
- The most senior housestaff member is responsible for assigning or performing and documenting abdominal examinations at an appropriate interval, but no less than every 12 hours.
- The examination should be documented in a progress note in the EMR. The note should record the physical examination of the abdomen, any changes from the previous examination, any changes in vital signs, and any requirements for analgesia.
- Any deteriorating exams must be discussed with the Chief Resident or Fellow, and the discussion must be documented.