Table 2-1: Documentation: Descriptive Words Ruth Herold, CTRS and Kristin Ogren, OTR/L Overlake Hospital and Medical Center, Bellevue, WA MOTOR Posture: Tense Relaxed Rigid Open/closed Slouching Slumped Head down Movements: Coordination Fine motor Jerking Self-stimulating Startles Restless Active Retardation Lethargic Balance Dexterity Handwriting (quality) Mannerism Aimless Pacing Spontaneous Fluid Listless Gait Eye-hand coordination Dyskinesia Gestures Purposeless Perseverating Strong Slow Passive Motor planning Tremor Rocking Hypermobile Overstimulated Abrupt Forceful Latent Tentative Gross motor Spasm Nervous habit Hyper-responsive Repetitive Agitated quick Delayed Offers States Produces Initiates Appears Situation-appropriate Declines Inconsistent Age-appropriate Reports Refuses Seems Observed Resists Retention Attention span Focused Hallucinations Aware Drowsy Delusions Perceptive Dull Reality testing Comprehension Alert Memory (recent, remote) Confused Preoccupied Distractible disoriented Thought Process: Tangential Processing Expansive Poverty of thought Pressured Abstracting Concrete thinking scattered Rambling Flight of ideas Grandiose Racing thoughts Generalizing Obsessive Tracking Blocked Disorganized Blunted Constricted Self-critical Staring Hopeless Tearful Lacking energy Tense Scowling Panicky Indignant Eager Happy Labile Bland Matter-of-fact Calm Relaxed Dejected Apprehensive Guilty Irritable Pressured Resentful Cheerful Energetic Spontaneous Disappointed Sober Composed Nonchalant Self-effacing Subdued Overwhelmed Frustrated Fearful Angry Bright Motivated Exhilarated Dazed Serious Comfortable Fixed expression Despondent Unhappy Powerless Anxious Frightened Sullen Smiling Interested Euphoric HELPFUL WORDS TO REMEMBER Shows Demonstrates Noted Withdraws COGNITIVE Mental State: Concentration Clear Insightful AFFECT Flat Controlled Placid Self-deprecatory Depressed Sad Remorseful Belligerent Puzzled Agitated Hostile Enthusiastic Animated Elated © 1990 Idyll Arbor, Inc. for ©1986 Herold and Ogren Table 2-1 (CONT.): Documentation: Descriptive Words Ruth Herold, CTRS and Kristin Ogren, OTR/L Overlake Hospital and Medical Center, Bellevue, WA TASK PERFORMANCE Following Directions: Follows written directions Follows verbal directions Needs hands-on assist Follows demonstrations Learns quickly Needs cuing Follows (1-2-or3) step directions Use of Time: Sets goals Slow to get started Works steadily Works intermittently Organized Realistic planning Utilizes time well Efficient Works slowly Plans ahead Irregular attendance Hurried Scattered Productive Skips steps Choice of Activity: Indecisive Quickly engages Hesitant Apathetic Takes initiative Slow to engage Resistant Indifferent Seeks challenging activity Decisive Ambivalent Chooses familiar activity Selects (type of activity) Persistent Interested Tolerates delays Impulsive Quality of work Persevering Follows through Accurate Reckless Seeks quick results Tolerates frustration Orderly Careful Careless Quick gratification Thorough Neat Cautious Use of judgment Disregards mistakes Seeks direction Accepts direction Disregards direction Needs reminding Seeks reassurance Self-sufficient Competent Refuses direction Independent Teaches others Needs repeated directions Unrealistic choice Detailed, short term Approach to Activity: Patient Eager Compulsive Recognizes mistakes Problem solving Unaware of mistakes Independence/Dependence: Responsible Self-reliant Debates suggestions Needs clarification Retains instructions Creative, repetitive SOCIAL Expressive Joking Congenial Engaging Agreeable Tactful Articulate Gracious Talkative Warm Open Self-disclosing Assertive Spontaneous Outspoken Cooperative Considerate Sensitive Sympathetic Care-taking Doting Tolerant Supportive Concerned Indifferent Apathetic Isolating Sense of humor Solitary Superficial Reserved Self-focused Guarded Suspicious Withdrawn Argumentative Seclusive Detached Passive Engages in power struggle Shy Timid Deferring Condescending Submissive Tentative Dependent Ingratiating Distrustful Docile Compliant Watchful Aggressive Threatening Dominating Forceful Intrusive Sarcastic Critical Provocative Cynical Flippant Competitive Boastful Social Behaviors: Placement of seating in group (isolates, dominates, on Eye contact (direct, occasional, elusive) fringe) Awareness of social/physical boundaries Group skills: parallel, competitive, cooperative Body posture: open, closed, accessible Verbal/nonverbal Selective interactions (peers, staff, men, women, young, Speech patterns (rapid, forced, spontaneous, latent) old) Tone of voice (monotone, inaudible, loud, soft) Quality of grooming Role of patient in group Response of peers to patient Patient response to authority © 1990 Idyll Arbor, Inc. for © 1986 Herold and Ogren
