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