SUGGESTED WORD LIST FOR DOCUMENTATION

Respirations
Regular
Irregular
Labored
Unlabored

Skin temperature
warm
cool
dry
diaphoretic

Ability to void and empty bladder

Incontinent
Continent
Unable to void
urinary catheter

Breath Sounds
Clear
Crackles
Gurgles
Wheezes
Identify location

Skin color
pink
pallor (pale)
mottled
jaundice
ashen
dusky

Abdomen
Soft
distended
tender
firm
non-tender

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

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

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