SUGGESTED WORD LIST FOR DOCUMENTATION

Respirations Regular Irregular Labored Unlabored Breath Sounds Clear Crackles Gurgles Wheezes Identify location Cough Spontaneous Productive Non-productive Sputum Clear Green Yellow Bloody Frothy Tan Consistency-viscous, thin, tenacious amount O, Nasal cannula mask Describe percentage or liters/minute Cardiac Rhythm regular irregular Heart Sounds Unremarkable distant strong murmur Edema 1+ to 4+ pitting non pitting Describe location Absent Peripheral Pulses palpable, present bounding thready doppled absent weak Capillary refill rapid return (recoil) (< 3 seconds) sluggish return (recoil) Calf tenderness no calf tenderness If present, describe location, make comparison Skin temperature warm cool dry diaphoretic Skin color pink pallor (pale) mottled jaundice ashen dusky Level of Consciousness Alert Lethargic Comatose Orientation Person, place, time, situation Speech clear slurred expressive aphasia receptive aphasia garbled Thought Processes Logical, orderly Appropriate/Inappropriate Scattered Delayed Pupils Equal Reactive to Light R>L, L>R Extremity Movement Spontaneous Purposeful Flaccid Weak Tremors Symmetry of Strength Grips equal and strong R>L, L>R Skin Turgor Rapid return (< 3 seconds) sluggish return Urine color Yellow straw amber hematuria Urine clarity clear cloudy sediment Ability to void and empty bladder Incontinent Continent Unable to void urinary catheter Abdomen Soft distended tender firm non-tender Bowel Sounds Present hyper/hypo/normoactive all quadrants Absent flatus Stool Continent Incontinent Last BM diarrhea Constipation formed stool presence of ostomy Skin condition Intact Lesion Dryness Ecchymosis Decubitus Describe location, appearance, size, dressing present Incision/Wound Describe location, appearance, size, sutures, clips present, drains dressing, draining present Pain Describe if present, location, nursing action to alleviate No c/o pain Psychosocial Appearance, behavior, verbalization appropriate to situation Inappropriate, describe behaviors indicating inappropriateness

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