The document provides a table of descriptive terms commonly used in charting with suggested terms to describe various factors that may be charted. The factors include things like the abdomen, amounts, appearance, appetite, arms, attitude, back, breathing, color, consciousness, consistency, cough, drainage, dressings, eyes, and more. For each factor, more objective terms are suggested to replace more subjective terms in charting to standardize documentation.

1. TABLE OF DESCRIPTIVE TERMS COMMONLY USED IN CHARTING
FACTORS TO BE CHARTED SUGGESTED TERMS TO USE
Abdomen
1. large and extends outward
2. black blue mark present
3. hard, boardlike
4. soft, flabby, flat
5. hurts when touched
6. appears swollen, rounded
7. presence of rash
8. filled with gas
9. scars present
1. enlarged, protruding
2. bruised
3. hard, rigid
4. relaxed, flacoid, flat
5. tender, sensitive to touch
6. distended
7. rash present (mild, severe)
8. tympanitic
9. scarified
Regions of abdomen
1. right hypochondriac region
2. epigastric region
3. left hypochondriac region
4. right lumbar region
5. umbilical area
6. left lumbar region
7. right iliac region
8. left iliac region
AMOUNTS
1. large amount
2. moderate amount
3. small amount
1. profuse, copious, fee, excessive
2. moderate, unusual measured amt.
3. scanty, slight, very little, measured
amt.
APPEARANCE IN GENERAL
1. thin and undernourished
2. fat, greatly, overweight
3. seems very sick
4. not very sick
1. emaciated
2. obese
3. acutely ill
4. not acutely ill
APPETITE
1. very fussy about food, refuses to eat
many foods
2. eats all food served
3. eats very little
4. loss of appetite
5. craving for certain foods
1. has definite likes and dislikes
concerning food
2. appetite good
3. appetite poor
4. anorexia
5. parorexia

2. 6. refuses to eat
7. eats only small amount
8. has desire to eat materials that are
not food
6. refused food (state reason)
7. appetite fair
8. perverted appetite
ARMS
1. shoulder to elbow
2. elbow to wrist
3. with accumulation of fat
4. appear puffy or swollen
5. right arm artificial
1. upper arm (right or left)
2. lower arm (right or left)
3. plump
4. edematous
5. artificial arm (rt.)
ATTITUDE (Mental)
1. not interested in the surroundings
2. has “I don’t care” attitude
3. doesn’t believe anything said to her
4. quarrelsome, disagreeable, wants to
argue
5. afraid, worried
6. happy, carefree, cheerful
1. indifferent
2. apathetic
3. suspicious, distrustful
4. belligerent, quarrelsome,
disagreeable
5. anxious, fearful
6. cheerful, optimistic
BACK (Areas)
1. upper back
2. small of the back
3. end of spine
4. buttocks
5. hump back
6. sway back
1. intrascapular region
2. lumbar region
3. sacral region
4. gluteal area
5. kyphosis
6. lordosis
BACKREST
1. backrest raised 1. backrest elevated (indicate deg. of
angle or no. of notches)
BATHS
1. given when patient is admitted
2. all-inclusive bath
3. include face, arms, back, axilla,
genitalia only
4. special baths (treatment)
5. taken in tub
6. taken in bed, by patient
1. admission bath
2. complete bath
3. partial bath
4. name of bath e.g. sitz bath
5. tub bath
6. self-administered
BELCH
1. belch 1. eructating, eructation

3. BLEEDING
1. spurting of blood
2. very little
3. nosebleed
4. blood in vomitus
5. blood in urine
6. spitting of blood
7. when bleeding is stopped
1. in spurts
2. oozing
3. epistaxis
4. hematemesis
5. hematuria
6. hemotysis
7. hemorrhage is controlled
BLISTER
1. blister 1. vesicle
BLOOD PRESSURE
1. blood pressure 120/74 1. B.P. 120/74
B.M.R.
1. basal metabolic rate 1. B.M.R.
BREAST
1. inflammation of
2. each of the same size
3. satisfactory in appearance
4. nipple always depressed
1. mastitis
2. equal size
3. develop normally
4. inverted nipple
BREATH
1. unpleasant
2. foul
3. with sweet, fruitlike odor
4. smells of alcohol
1. halitosis
2. fetid
3. fruity, sweet
4. alcoholic
BREATHING
1. act of breathing
2. act of inhaling
3. act of exhaling
4. difficult breathing
5. short breathing when breathing ceases
6. inability to breath while lying down
7. normal breathing
8. rapid breathing
9. increasing dyspnea with period of apnea
10. large volume of air inspired
11. small volume of air inspired
12. abnormal volume of air inspired
13. suffocation
1. respiration
2. inspiration
3. expiration
4. dyspnea
5. apnea
6. orthopnea
7. eupnea
8. hyperpnea, tachypnea
9. cheyne-strokes respiration
10. deep breathing
11. shallow breathing
12. irregular respiration
13. asphyxia

4. CARE
1. wash face and hands, mouth toilette,
bedpan in the morning
2. bath, alcohol backrub, bedpan, mouth
toilette, care of hair and nails
3. wash hands, face and back, backrub
bedpan, mouth toilette
4. 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)
CHEST
1. looks abnormally small
2. abnormally shaped
3. burst when moving or breathing
1. shrunken, atrophied
2. deformed
3. pain on moving/breathing
CHILL
1. blanket applied to help warm the
patient (if hot water bottles also
applied)
2. severity (degree of)
3. type or kind
4. duration
5. came on suddenly
1. external heat applied/ H. W. B. 125
applied
2. severe, moderate, slight
3. nervous, etc.
4. protracted, persisted, of short
duration
5. sudden onset
COLOR
1. colorless
2. of normal urine
3. resembling clay
4. looks same as tar
5. tinged with blood
1. clear
2. amber
3. clay-colored
4. tarry
5. blood-tinged, blood streaked
COMA
1. partly in coma
2. in deep coma
1. partially comatose
2. profound coma
CONSCIOUSNESS
1. fully conscious, aware of
surroundings
2. only partly conscious
3. unconscious but can be aroused
4. unconscious, cannot be aroused
1. alert, fully conscious
2. semiconscious
3. stuporous
4. comatose

5. CONSISTENCY
1. retains its shape
2. watery
3. thick, sticky or gross like
4. ~ or resembling mucus
1. formed
2. liquid, liquefied
3. concentrated, tenacious
4. mucoid
CONVULSIONS
1. continuous shaking
2. shaking ~
3. ~
4. spasm or resembling ~
1. tonic tremor
2. clonic tremor
3. sudden onset
4. paroxysm
COUGH
1. coughs all the time
2. coughing over long period of time
3. coughs up materials
4. occurring in spasms
5. coughs quite often
6. cough that does not produce material
from lungs
7. with characteristics “whoop” on
inspiration
8. occurs to paroxysm or attack
9. others self-explanatory terms used to
describe a cough includes
1. continuous cough
2. persistent cough
3. productive cough
4. spasmodic cough
5. frequent cough
6. nonproductive cough
7. whooping cough
8. paroxysmal cough
9. tight, loose, deep, dry, hacking,
harsh, painful, explosive, hollow,
crowing, exhaustive
DECAY
1. of teeth
2. of tissues
1. dental carries
2. neurosis
DEFECATION
1. bowel (material)
2. bowel movement
3. grab-colored stool
4. dark brown liquid stool
5. formed yet soft stool
6. formed with hardened feces
1. feces
2. stool defecation
3. clay-colored stool
4. highly colored liquid stool
5. soft-formed stool
6. hard-formed stool
DIZZINESS
1. dizziness 1. vertigo

6. DRAINAGE
1. watery, from nose
2. containing pus
3. consist of feces
4. consist of feces
5. of lymphatic fluid
6. contains mucus and pus
7. tough, sticky
8. from vagina
1. coryza
2. purulent
3. sanguinous
4. fecal, fecaloid
5. serous
6. mucopurulent
7. tenacious
8. lochia
DRESSINGS
1. a second dressing added to the first
2. dressing removed, another applied
3. drain tubes cut off
1. dressing reinforced
2. dressing changed
3. drain tubes shortened (no. of
inches)
DROP
1. drop
2. drops
1. gtt.
2. gtts.
EARS
1. wax in the ears
2. ringing in the ears
3. dizziness
4. abnormal in shape
1. cerumen
2. tinnitus aurium
3. vertigo
4. deformed
ENEMAS
1. to induce bowel movement
2. to supply nourishment
3. to relieve distention caused by gas
4. to expel worms
5. to be retained for several hours
6. to stimulate
7. to aid in fluoroscopic exams
1. cleansing enema
2. nutritive enema
3. carmicative enema
4. antihelmentic enema
5. retention enema
6. stimulating enema
7. barium enema
EMESIS
1. produced by effort of patient
2. ejected to few feet distance
3. if blood is only noted
4. agent given to produce emesis
1. induced
2. projectile
3. blood-tinged
4. emetic
EXPECTORATION
1. a great deal
2. very little
3. spitting up blood (from the lungs)
1. profuse
2. scanty
3. hemoptysis

7. EYES
1. sharpness of vision
2. yellow in color
3. puffy, swollen
4. drooping of lids
5. motionless, not moving, ~
6. unusually sensitive to light
7. double vision
8. squinting or cross-eyed
9. abnormal protrusion of the eyeball
10. inflammation of conjunctive
11. dilation of the pupil
12. near-sightedness
13. constriction of the pupil
14. far-sightedness
15. sees objects indistinctly
1. visual acuity
2. jaundiced
3. edematous
4. ptosis of lids
5. fixed
6. photophobia
7. diplopia
8. strabismus
9. exopthalmus
10. conjunctivitis
11. pupil dilated
12. myopia
13. pupil constricted
14. hyperopia
15. blurred vision