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Discussion

Nurse Progress Note About Vomit

I am an international nurse and my medical English is not very good. I had a patient who vomited and I want to write about how much she vomited and what kind of things she vomit, but I don't know the exact English words to describe the vomiting thing. Is there anyone who knows where I can find an example on what a progress note looks like and what kind of words I can use to describe vomiting?

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    Are there words in your language that describes it? How would you describe it.

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    Small, medium, large emesis. I don't typically describe it unless there's something unique or important-- say it has a coffee grounds appearance (indicative of a GI bleed), or pill fragments present (meaning pt did not get full doses), or if I noted some being expelled from the pt's trach (true story.)

    Ordinary vomit containing dinner...no. Unless I want to nauseate myself. :barf02:

    And of course I include what (if anything) preceded the episode, my interventions and effectiveness, etc.

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    Projectile vomiting can be used if the patient vomits and it spews out like a faucet or water hose. A poster above had a good suggestion when he said describe it in your primary language, then translate that into English for the purpose of your nurse's progress notes.

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