TABLE OF DESCRIPTIVE TERMS COMMONLY USED IN CHARTING

FACTORS TO BE CHARTED SUGGESTED TERMS TO USE

Abdomen1. large and extends outward2. black blue mark present3. hard, boardlike4. soft, flabby, flat5. hurts when touched6. appears swollen, rounded7. presence of rash8. filled with gas9. scars present

1. enlarged, protruding2. bruised3. hard, rigid4. relaxed, flacoid, flat5. tender, sensitive to touch6. distended7. rash present (mild, severe)8. tympanitic9. scarified

Regions of abdomen1. right hypochondriac region2. epigastric region3. left hypochondriac region4. right lumbar region5. umbilical area6. left lumbar region7. right iliac region8. left iliac region

AMOUNTS1. large amount2. moderate amount3. small amount

1. profuse, copious, fee, excessive2. moderate, unusual measured amt.3. scanty, slight, very little, measured

amt.

APPEARANCE IN GENERAL1. thin and undernourished2. fat, greatly, overweight3. seems very sick 4. not very sick

1. emaciated2. obese3. acutely ill4. not acutely ill

APPETITE1. very fussy about food, refuses to eat

many foods2. eats all food served3. eats very little4. loss of appetite5. craving for certain foods

1. has definite likes and dislikes concerning food

2. appetite good3. appetite poor4. anorexia5. parorexia

6. refuses to eat7. eats only small amount8. has desire to eat materials that are

not food

6. refused food (state reason)7. appetite fair8. perverted appetite

ARMS1. shoulder to elbow2. elbow to wrist3. with accumulation of fat4. appear puffy or swollen5. right arm artificial

1. upper arm (right or left)2. lower arm (right or left)3. plump4. edematous5. artificial arm (rt.)

ATTITUDE (Mental)1. not interested in the surroundings2. has “I don’t care” attitude3. doesn’t believe anything said to her4. quarrelsome, disagreeable, wants to

argue5. afraid, worried6. happy, carefree, cheerful

1. indifferent2. apathetic3. suspicious, distrustful4. belligerent, quarrelsome,

disagreeable5. anxious, fearful6. cheerful, optimistic

BACK (Areas)1. upper back2. small of the back 3. end of spine4. buttocks5. hump back6. sway back

1. intrascapular region2. lumbar region3. sacral region4. gluteal area5. kyphosis6. lordosis

BACKREST1. backrest raised 1. backrest elevated (indicate deg. of

angle or no. of notches)

BATHS1. given when patient is admitted2. all-inclusive bath3. include face, arms, back, axilla,

genitalia only4. special baths (treatment)5. taken in tub6. taken in bed, by patient

1. admission bath2. complete bath3. partial bath4. name of bath e.g. sitz bath5. tub bath6. self-administered

BELCH1. belch 1. eructating, eructation

BLEEDING1. spurting of blood2. very little3. nosebleed4. blood in vomitus5. blood in urine6. spitting of blood7. when bleeding is stopped

1. in spurts2. oozing3. epistaxis4. hematemesis5. hematuria6. hemotysis7. hemorrhage is controlled

BLISTER1. blister 1. vesicle

BLOOD PRESSURE1. blood pressure 120/74 1. B.P. 120/74

B.M.R.1. basal metabolic rate 1. B.M.R.

BREAST1. inflammation of2. each of the same size3. satisfactory in appearance4. nipple always depressed

1. mastitis2. equal size3. develop normally4. inverted nipple

BREATH1. unpleasant2. foul3. with sweet, fruitlike odor4. smells of alcohol

1. halitosis2. fetid3. fruity, sweet4. alcoholic

BREATHING1. act of breathing2. act of inhaling3. act of exhaling4. difficult breathing5. short breathing when breathing ceases6. inability to breath while lying down7. normal breathing8. rapid breathing9. increasing dyspnea with period of apnea10. large volume of air inspired11. small volume of air inspired12. abnormal volume of air inspired13. suffocation

1. respiration2. inspiration3. expiration4. dyspnea5. apnea6. orthopnea7. eupnea8. hyperpnea, tachypnea9. cheyne-strokes respiration10. deep breathing11. shallow breathing12. irregular respiration13. asphyxia

CARE1. wash face and hands, mouth toilette,

bedpan in the morning2. bath, alcohol backrub, bedpan, mouth

toilette, care of hair and nails3. wash hands, face and back, backrub

bedpan, mouth toilette4. special attention or treatment of mouth

or back as ordered by the doctors

1. early A.M. care

2. routine A.M. care

3. P.M. care

4. special care to (mouth, back)

CHEST1. looks abnormally small2. abnormally shaped3. burst when moving or breathing

1. shrunken, atrophied2. deformed3. pain on moving/breathing

CHILL1. blanket applied to help warm the

patient (if hot water bottles also applied)

2. severity (degree of)3. type or kind4. duration5. came on suddenly

1. external heat applied/ H. W. B. 125 applied

2. severe, moderate, slight3. nervous, etc.4. protracted, persisted, of short

duration5. sudden onset

COLOR1. colorless2. of normal urine3. resembling clay4. looks same as tar5. tinged with blood

1. clear2. amber3. clay-colored4. tarry5. blood-tinged, blood streaked

COMA1. partly in coma2. in deep coma

1. partially comatose2. profound coma

CONSCIOUSNESS1. fully conscious, aware of

surroundings2. only partly conscious3. unconscious but can be aroused4. unconscious, cannot be aroused

1. alert, fully conscious2. semiconscious3. stuporous4. comatose

CONSISTENCY1. retains its shape2. watery3. thick, sticky or gross like4. ~ or resembling mucus

1. formed2. liquid, liquefied3. concentrated, tenacious4. mucoid

CONVULSIONS1. continuous shaking2. shaking ~3. ~4. spasm or resembling ~

1. tonic tremor2. clonic tremor3. sudden onset4. paroxysm

COUGH1. coughs all the time2. coughing over long period of time3. coughs up materials4. occurring in spasms5. coughs quite often6. cough that does not produce material

from lungs7. with characteristics “whoop” on

inspiration8. occurs to paroxysm or attack9. others self-explanatory terms used to

describe a cough includes

1. continuous cough2. persistent cough3. productive cough4. spasmodic cough5. frequent cough6. nonproductive cough

7. whooping cough

8. paroxysmal cough9. tight, loose, deep, dry, hacking,

harsh, painful, explosive, hollow, crowing, exhaustive

DECAY1. of teeth2. of tissues

1. dental carries2. neurosis

DEFECATION1. bowel (material)2. bowel movement3. grab-colored stool4. dark brown liquid stool5. formed yet soft stool6. formed with hardened feces

1. feces2. stool defecation3. clay-colored stool4. highly colored liquid stool5. soft-formed stool6. hard-formed stool

DIZZINESS1. dizziness 1. vertigo

DRAINAGE1. watery, from nose2. containing pus3. consist of feces4. consist of feces5. of lymphatic fluid6. contains mucus and pus7. tough, sticky8. from vagina

1. coryza2. purulent3. sanguinous4. fecal, fecaloid5. serous6. mucopurulent7. tenacious8. lochia

DRESSINGS1. a second dressing added to the first2. dressing removed, another applied3. drain tubes cut off

1. dressing reinforced2. dressing changed3. drain tubes shortened (no. of

inches)DROP

1. drop2. drops

1. gtt.2. gtts.

EARS1. wax in the ears2. ringing in the ears3. dizziness4. abnormal in shape

1. cerumen2. tinnitus aurium3. vertigo4. deformed

ENEMAS1. to induce bowel movement2. to supply nourishment3. to relieve distention caused by gas4. to expel worms5. to be retained for several hours6. to stimulate7. to aid in fluoroscopic exams

1. cleansing enema2. nutritive enema3. carmicative enema4. antihelmentic enema5. retention enema6. stimulating enema7. barium enema

EMESIS1. produced by effort of patient2. ejected to few feet distance3. if blood is only noted4. agent given to produce emesis

1. induced2. projectile3. blood-tinged4. emetic

EXPECTORATION1. a great deal2. very little3. spitting up blood (from the lungs)

1. profuse2. scanty3. hemoptysis

EYES1. sharpness of vision2. yellow in color3. puffy, swollen4. drooping of lids5. motionless, not moving, ~6. unusually sensitive to light7. double vision8. squinting or cross-eyed9. abnormal protrusion of the eyeball10. inflammation of conjunctive11. dilation of the pupil12. near-sightedness13. constriction of the pupil14. far-sightedness15. sees objects indistinctly

1. visual acuity2. jaundiced3. edematous4. ptosis of lids5. fixed6. photophobia7. diplopia8. strabismus9. exopthalmus10. conjunctivitis11. pupil dilated12. myopia13. pupil constricted14. hyperopia15. blurred vision