Medical Terminology Charting Terms

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


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


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


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


1. Large amount or profuse 1. Diaphoresis

2. Small amount 2. Scanty

Concerning: Odor


1. Not unpleasant 1. Aromatic2. Like ammonia 2. Ammonial

3. Very unpleasant 3. Offensive, foul

Education

Medical Terminology Charting Terms