SUGGESTED WORD LIST FOR DOCUMENTATION

Respirations Skin temperature Ability to void and empty bladder

Regular warm Incontinent
Irregular cool Continent
Labored dry Unable to void
Unlabored diaphoretic urinary catheter

Breath Sounds Skin color Abdomen

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