Quote from willdgate
What are the correct terminology to use when charting on the nursing notes? ex. use eyes closed vs. awake, in no pain
Are you talking in general, or specifically regarding the neuro exam? Also, what unit, what kind of patient (adult, pediatric), and what diagnosis?
I.e. a neuro patient requires a more focused neuro exam. Maybe they are sleeping, but easily awake with verbal stimulation, or tactile (tap them on the shoulder), or possible require a combination of verbal and tactile (you have to say their name and tap them at the same time to wake them), but don't have to resort to painful stimulation.
You could be vague, and say "awakens with stimulation." Maybe you could be more specific and use the type or combination of types of stimulation, and chart the immediate response. I.e. "Awakens (I hate the word "arouse"), with loud verbal stimulation and immediately falls back asleep." Chart if this is a change from the previous exam. Chart the level of orientation if the patient remains awake and can participate, i.e. follows commands, oriented to person, place, time.
Really, just document the facts as they relate to your patient.
Maybe this isn't what you were looking for?