Proper wording on assessment???

Altra, BSN, RN · May 17, 2005

I am in first year of clinicals and we have a 4 page assessment to fill out on our pt. Silly question, but in one area for example it has appearance, posture, facial expression and behavior. What is proper wording for stuff like that? Is there a website for terminology like that? I don't know if there are acutally medical terms for that, or just use "normal" words!

Some possibilities ...

General appearance is often worded something like, "Pt. is a white male lying in bed. Appearance consistent with stated age. Pt. appears well-nourished / undernourished." Things listed under appearance are observations. I've also been taught to note the appearance of the pt.'s room - cards, flowers, or other evidence of family?

Posture ... think about kyphosis, lordosis, etc. Ambulates independently or with assistance (assistance from staff or use of assistive devices)

Facial expression ... does the pt. appear calm, relaxed, anxious, hostile ... are they grimacing in pain?

Behavior ... overall mood, affect, or specific behaviors that should be documented (pt. made 3 attempts to get out of bed without calling for assistance ... pt. refuses physical therapy, etc.)

The best way to pick up on charting conventions is to continue to read charts ... before you know it the "lingo" will be second nature to you!

HTH :)

ashemson · May 17, 2005

Thanks, that helps. I actually work in a hospital so I am familiar w/ medical terms, but I can't seem to put anything "normal" wording!! :)

Granted Fal · May 17, 2005

when you're at the clinical site, read the other assessments of the facility you are at in the charts to get a feel for different nurse's approaches. A lot of times they assessment is a chart-by-exception checklist that only really allows you to focus on what is abnormal... also in nursing homes the assessments are very often much like the DR's assessment.