MEDICAL RECORD TERMS
CONCERNING FACTORS TO BE CHARTED SUGGEST TERMS TO USE
ABDOMEN
1. large and extends outward2. hard, board-like
3. soft, flabby4. hurts when touched
5. appears swollen, rounded6. filled with gas7. hangs down over pubis
1. protuberant, distended2. hard, rigid, distended, tympanic,
taut3. relaxed, flaccid4. sensitive to touch, tender,
painful, intense5. distended, edematous6. tympanites, tympanic, flatulent7. pendulous
ANATOMICAL DESCRIPTION OF ABDOMEN:
right/left hypochondriac region epigastric region right/left lumbar region unbilical region right/left inguinal (iliac) region pubic (hypogastric) region right/left upper quadrant right/left lower quadrant
AMOUNTS
1. large amounts of drainage and/or emesis
2. medium amount of drainage3. small amount of drainage
1. profuse, copious, large, abundant (indicate amount in cc.)
2. moderate3. small amount, scanty, slight,
very little
APPETITES
1. condition of appetite
2. loss of appetite
3. craving for certain foods
1. has definite likes and dislikes concerning food; appetite good, fair, poor, or refused food
2. anorexia3. parorexia
ARMS
1. shoulder-to-elbow2. elbow-to-wrist
1. upper arm, right or left humerus2. lower arm, right or left ulna and
radius
CONCERNING FACTOR TO BE CHARTED SUGGESTED TERMS TO USE
BACK
1. upper back2. small of back3. end of spine4. buttocks
1. interscapular region, shoulder area
2. lumbar region3. sacral region, coccyx or
coccygeal area4. gluteal area
BATHS
1. all inclusive bath2. bath with assistance – dependent on
client’s degree of self-care
1. complete bath2. partial bath
3. shower4. tub bath5. identify type; e.g., sitz, etc
BELCH 1. belching 1. eructation
BLEEDING
1. very little2. nosebleed3. blood in urine4. spitting of blood5. when bleeding is stopped6. spurting of blood7. uncontrolled8. emesis of blood
1. degree of oozing, small amount, scanty, slight
2. epistaxis3. hematuria4. hemoptysis5. hemorrhage, controlled,
terminated6. in spurts, ejecting, intermittent7. continuous8. hematomesis
BLISTER 1. blister 1. vesicleBREAST 1. depressed nipple 1. inverted nipple
BREATHING
1. breathing2. act of inhaling3. act of exhaling4. difficult breathing5. short periods when breathing has
ceased.6. inability to breath lying down7. normal breathing8. rapid breathing9. increasing dyspnea with period of apnea10. large volume of air inspired or expired11. small volume of air inspired or expired12. abnormal variations in rhythm13. laborious and noisy
1. respiration2. inspiration3. expiration4. dyspnea5. apnea6. orthopnea7. eupnea8. hypernea9. Cheyne-Stokes respiration10. deep breathing11. shallow breathing12. irregular respiration13. stertorous
CHILL1. type as to severity2. duration
1. severe, moderate, or slight2. specify time
CONSCIOUSNESS
1. fully conscious, aware of surroundings2. only partly conscious3. unconscious, but arousable4. unconscious; not arousable
1. alert; fully conscious
2. self-conscious3. stuporous4. comatose
CONVULSION
1. continuous shaking2. shaking with intervals of rest3. subjective sensation4. began without warning
1. tonic tremor; palsy2. clonic tremor3. aura4. sudden onset
COUGH
1. type of coughing
2. occurring in spasms3. expulsion of mucus or phlegm from
throat or lungs
1. continuous, persistent, productive, non-productive, dry, hacking
2. spasmodic3. expectorate
DECAY1. of teeth2. of tissue
1. dental caries2. necrosis
DEFECTION
1. bowel movementa. materialb. act of
2. frequent liquid defection3. color of stool
4. description of stool
1. a. feces, stoolb. act of defecation,
elimination, evacuation2. diarrhea3. clay or dark brown, black,
mustard, yellow, green, tarry, streaked with blood
4. liquid, soft- or hand-formed, watery, semi-formed, constipated, undigested foods, mucoid
DISSINESS 1. dizziness 1. dizziness
DRAINAGE 1. water, from nose2. containing pus3. bloody4. consists of feces5. of serum
1. coryza2. purulent3. sanguineous4. fecal5. serous
6. contains mucus and pus7. tough, sticky8. from vagina (after delivery)9. bloody, serum
6. mucopurulent7. tenacious8. lochia9. sero-sanguineous
CONCERNING FACTOR TO BE CHARTED SUGGESTED TERMS OF USE
EARS1. wax in ears2. ringing, buzzing, clicking, roaring noise
in the ears
1. cerumen2. ringing, buzzing, clicking,
roaring noise in the ears
EMESIS
1. produced by conscious effort of client2. ejected a few feet distant3. if blood is noticeable
4. agent given to produce emesis
1. induced
2. projectile3. blood-tinged, dark or bright red;
hematomosis4. emetic
EYES
1. sharpness of vision2. yellow in color3. puffy, swollen4. drooping eyelids5. motionless; not moving6. unusually sensitive to light7. double=vision8. cross-eye; squinting9. abnormal protrusion of eyeball10. inflammation of conjunctiva11. dilation of the pupil12. contraction of the pupil
13. nearsightedness14. farsightedness15. sees objects indistinctly16. other characteristic terms
1. visual acuity2. jaundiced3. edematous4. ptosis of lids5. fixed6. photophobia7. diplopia8. strabismus9. exophthalmos10. conjunctivitis11. mydriasis; pupil dilated12. myosis; pupil constricted, pin
point13. myopia14. myperopia15. blurred vision16. bright, clear, dull, sunken,
inflamed, bloodshot, burning
FAINT 1. fainting Syncope
FEVER 1. without fever2. temperature above normal3. temperature greatly above normal4. temperature suddenly returns to normal5. temperature gradually returns to normal
1. afebrile2. pyrexia3. hyperpyrexia4. crisis
5. lysis
GAS 1. gas in the digestive tract 1. flatus or flatulence
GUMS1. inflammation of the gums2. gum boil
1. gingivitis2. abscessed gum
HALLUCINATION
1. of hearing2. of sight3. of smell4. of taste
1. auditory hallucination2. visual hallucination3. olfactory hallucination4. gustatory hallucination
HEAD
1. forehead2. region over temple3. back of head4. base of skull5. having a large head6. having a small head7. top of head
1. frontal region2. temporal region3. occipital region4. basilar region5. macrocephalous; hydrocephalus6. microcephalous7. parietal-right or left
JOINTS
1. bending2. to straighten3. turn downward4. turn upward5. revolve around6. move away from median line7. move toward median line8. stiff joint
FlexionExtensionPronationSsupinationRotationAbductionAdductionAnkylosis
LEGS1. thigh to knew2. knee to ankle
1. upper leg – right or left2. lower leg – right or left
LICE1. body; pubic2. head
1. pediculi2. pediculi capiti
HIVES1. hives2. itching
1. urticaria2. pruritus
MEDICINE(Administration of)
1. by mouth2. by rectum3. breathing in4. rubbing into skin5. under the skin6. within the skin7. within the muscle8. within the spinal cord9. within the vein10. pouring into body cavity11. blowing into body cavity
1. orally2. rectally3. inhalation 4. inunction5. subcutaneous6. intradermal7. intramuscular8. intraspinal9. intravenous10. instillation11. insufflation
CONCERNING FACTOR TO BE CHARTED SUGGESTED TERMS TO USE
MENSTRUATION
1. if present when admitted
2. if starts after admission
3. painful3. total absence of4. profuse or prolonged flow5. occurring between periods6. cessation of
1. catamenia present; menses present
2. catamenia established; menses established
3. dysmenorrheal4. amenorrhea5. menorrhagia6. metrorrhagia7. menopause
MENTAL ATTITUDE
1. distrustful
2. happy
3. sad
4. afraid
5. lacks of emotional control
6. loss of memory (amnesia, fugue)
1. questions staff repeatedly regarding care and administration of medication
2. smiles and laughs frequently; interacts verbally with ease with others clients and staff
3. . flat affect – eyes downcast, does not join in client activities; answers in monosyllables when questioned
4. . startled when spoken to; checks rooms before entering by peering into the room
5. vacillates between weeping openly and laughing boisterously
6. recalls nothing for a period from
____ to ____
NOURISHMENT
1. very small amount of water2. small pieces of ice3. drink of water4. given through tube into stomach5. given by enema
1. sips of water2. chipped ice, ice chips3. water – number of cc.4. gavage, tube feeding5. as nutritive enema
CONCERING FACTOR TO BE CHARTED SUGGESTED TERMS OF USE
ODOR
1. not unpleasant2. like ammonia3. very unpleasant4. belonging to particular drug, etc.
1. aromatic2. ammoniacal3. offensive; foul4. characteristic
PAIN
1. great pain2. little3. comes in seizures4. spreads to distant areas5. started all at once6. hurts worse when moving7. other descriptive terms8. referred or reflex pain felt in a part
distant from the part of its origin
1. severe2. slight3. paroxysmal, spasmodic4. radiating5. sudden onset6. increased by movement7. sharp, sudden, darting, gnawing,
burning, stabbing, cramping, shooting, persistent, transient, constant, shifting, localized, agonizing, dull, fixed, deep, superficial
PARALYSIS
1. of the muscles of the face2. of the legs3. of one side of the body4. of a single limb5. of all four limbs
1. facial2. paraplegia3. hemiplegia4. monoplegia5. quadriplegia
CLIENT (Admission)
1. walking2. carried (infant)3. by wheelchair4. by stretcher5. by ambulance
1. ambulatory2. in arms3. per wheelchair4. per stretcher, gumey, cart5. per ambulance
CLIENT (discharge)
1. was not dismissed by doctor; signed necessary paper
1. signed own releases AMA (against medical advice); accompanied by friend, family; or unaccompanied
PERSPIRATIONS1. large amount of profuse2. small amount
1. diaphoresis2. scanty
POSITIONS
1. flat on back, arms straight at side2. on side, knees flexed3. on left side, left arm behind back, left leg
slightly flexed4. head of bed erect5. head of bed semi=erect6. on back, buttocks near edge of table,
knees well flexed and separated7. on back, knees flexed and apart, feet flat
on table or bed8. resting on knees and chest9. on back, pelvis and legs higher than head10. on abdomen, face turned to one side
1. supine2. lateral3. Sims’- left or right4. Fowler’s 80 – modified, knees
and legs not flexed5. Semi-Fowler’s ro-45- modified,
knees and legs not flexed6. lithotomy7. dorsal recumbent8. knee-chest9. Trendelenburg
10. prone
PULSE
1. number of beats per minute2. rhythm
3. beats missed at intervals4. over 100 beats per minute5. less than 60 beats per minute6. one scarcely perceptible7. with excessive recoil wave8. pulseless9. pulse volume, quality
10. normal
1. rate2. regular or irregular, coupling,
galloping3. intermittent4. rapid, tachycardia5. slow, bradycardia6. thready, weak7. dicrotic8. imperceptible9. good, fair, poor, barely
perceptible10. normal in rate and rhythm
RESPIRATION
1. act of breathing2. fast or rapid respirations3. induced by artificial means4. snoring5. difficult breathing6. without breathing7. other descriptive terms
1. respiration2. hyperpnea3. artificial4. stertorous5. dyspnea6. apnea7. quite, sighing, gasping, shallow,
deep, costal, noisy
RESTRAINTS1. flannel wrist and ankle2. leather wrist and ankle3. waist
1. soft restraint2. leather restraint3. posey
CONCERNING FACTOR TO BE CHARTED SUGGESTED TERMS TO USE
SENSATION
1. tingling2. of extreme heat, burning3. stinging4. prickling
1. tingling 2. of extreme heat, burning3. stinging4. prickling
SKIN
1. normal2. pink3. blue in color4. very white5. shines6. raw surface7. yellow in clor8. torn9. containing colored areas10. wet11. scraped12. cold and moist13. birth mark14. wart15. boil16. other descriptive terms
17. indicate presence of
18. a discolored spot19. large irregular-formed hemorrhagic
spots on skin20. small hemorrhage spots on skin21. pimple with pus
1. healthy2. flushed3. cyanotic4. extreme pallor, ashen5. glossy6. excoriation7. jaundiced8. lacerated9. pigmented10. moist11. abraded, denuded12. clammy13. birth mark14. verruca15. furuncle16. mottled, discolored, dry, hot,
cold, warm, oily, broken, calloused, wrinkled, tight, coarse, of fine texture, tanned.
17. rash, brasion, laceration, insect bites, tumor, eruptions, acne, crusts, scars, ulcers, moles, fissures, abscesses
18. macule
19. ecchymosis20. petechiae21. pustule
SLEEP
1. tired when awakens2. slept very little3. moans while sleeping4. inability to sleep
1. tired when awakens2. slept very little3. moans will sleeping4. insomnia
SPEECH
1. not understandable2. meaningless; wandering3. words run together4. difficulty speaking5. unable to speak
1. incoherent2. rambling3. slurring4. dysphasia5. aphasia
CONCERNING FACTOR TO BE CHARTED SUGGESTED TERMS TO USE
TEETH1. false teeth2. collection of dark brown foul matter on
lips or teeth
1. dentures – upper and/or lower, partial, removable bridge, permanent bridge
2. sordes
THROAT1. difficulty in swallowing2. inability to swallow3. other descriptive terms
1. dysphagia2. aphagia3. red, swollen, inflamed, ulcerated
TONGUE 1. descriptive terms1. pink, moist, dry, cracked, swollen, coated, inflamed, ulcerated
UNCONSCIOUS-NESS
1. complete unconsciousness2. partial unconsciousness3. pretended unconsciousness
1. comatose2. stuporous and semi-comatose3. feigned unconsciousness
URINATION
1. to urinate2. no control over urination3. burning when voids4. large amount of urine voided5. total suppression of urine6. frequent voiding at night7. increased amount voided8. painful urination9. pus in urine10. blood in urine11. hemoglobin in urine12. albumin in urine13. acetone in urine14. bile in urine15. scantiness of urine16. sugar in urine17. bedwetting18. stones
1. void, to micturate2. oncontinence3. burning sensation micturition4. diuressis5. anuria6. nocturia7. polyuria8. dysuria9. pyuria10. hematuria11. hemoglobinuria12. albuminuria13. acetonuria14. choluria15. oliguria16. glycosuria17. enuresis18. calculi
VOMIT 1. (Refer to Emesis)
WEIGHT1. overweight 2. abnormal thinness3. very underweight
1. obese2. emaciated, wasting3. cadaverous, cachectic
WOUNDS
1. deep2. slight, surface
3. not infected4. discharging pus5. infected6. torn
1. deep, perforating, puncture2. superficial, contusion, abrasion,
subcutaneous3. clean, 4. suppurating5. infected6. lacerated, severed
EXAMPLES OF CHARTING TERMS
Concerning: Defecation
Factor To Be Charted Suggested Terms To Use1. Bowel movement:
a. materialb. act of
1. a. Feces, stool b.Defecation, elimination, evacuation
2. Frequent liquid defecation 2. diarrhea3. Color of stool 3. Clay or dark brown, black, mustard,
yellow, green, tarry, streaked with blood4. Description of stool 4. Liquid, soft or hard formed, watery,
semi-formed, constipated, undigested foods, mucoid
Concerning: Urination
Factor To Be Charted Suggested Terms To Use
1. to urinate 1. void, to micturate
2. no control over urination 2. incontinence
3. burning when voids 3. burning sensation on micturition
4. large amount of urine voided 4. diuresis
5. total suppression of urine 5. anuria
6. frequent voiding at night 6. nocturia
7. increased amount voided. 7. polyuria
8. painful urinated 8. dysuria
9. pus in urine 9. pyuria
10. blood in urine 10. hematuria
11. hemoglobin in urine 11. hemoglobinuria
12. albumin in urine 12. albuminuria
13. acetone in urine 13. acetonuiria
14. bile in urine 14. choluria
15 scantiness of urine 15 oliguria
16 sugar in urine 16. glycosuria
17. bedwetting 17. enuresis
18. stones 18. calcuili
Concerning: Perspiration
Factor To Be Charted Suggested Terms To Use
1. Large amount or profuse 1. Diaphoresis
2. Small amount 2. Scanty
Concerning: Odor
Factor To Be Charted Suggested Terms To Use
1. Not unpleasant 1. Aromatic2. Like ammonia 2. Ammonial
3. Very unpleasant 3. Offensive, foul