Scribd Logo
Upload

Welcome to Scribd!

  • 662 views

    Mood Affect....

    Uploaded by

    Michael Reid
    This document provides descriptive words to document a patient's motor skills, cognitive state, affect, task performance, and social behaviors. The words are organized into categories and include options like tense or relaxed posture, focused or confused thought processes, cheerful or depressed affect, independent or dependent task performance, and open or withdrawn social behaviors. Using these words can help therapists and medical professionals thoroughly yet concisely document a patient's presentation.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Mood Affect....

    Uploaded by

    Michael Reid
    662 views3 pages
    This document provides descriptive words to document a patient's motor skills, cognitive state, affect, task performance, and social behaviors. The words are organized into categories and include options like tense or relaxed posture, focused or confused thought processes, cheerful or depressed affect, independent or dependent task performance, and open or withdrawn social behaviors. Using these words can help therapists and medical professionals thoroughly yet concisely document a patient's presentation.

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides descriptive words to document a patient's motor skills, cognitive state, affect, task performance, and social behaviors. The words are organized into categories and include options like tense or relaxed posture, focused or confused thought processes, cheerful or depressed affect, independent or dependent task performance, and open or withdrawn social behaviors. Using these words can help therapists and medical professionals thoroughly yet concisely document a patient's presentation.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    662 views3 pages

    Mood Affect....

    Uploaded by

    Michael Reid
    This document provides descriptive words to document a patient's motor skills, cognitive state, affect, task performance, and social behaviors. The words are organized into categories and include options like tense or relaxed posture, focused or confused thought processes, cheerful or depressed affect, independent or dependent task performance, and open or withdrawn social behaviors. Using these words can help therapists and medical professionals thoroughly yet concisely document a patient's presentation.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Table 2-1: Documentation: Descriptive Words

    Ruth Herold, CTRS and Kristin Ogren, OTR/L


    Overlake Hospital and Medical Center, Bellevue, WA
    MOTOR
    Posture:
    Tense Rigid Slouching Slumped Head down
    Relaxed Open/closed
    Movements:
    Coordination Balance Gait Motor planning Gross motor
    Fine motor Dexterity Eye-hand coordination Tremor Spasm
    Jerking Handwriting (quality) Dyskinesia Rocking Nervous habit
    Self-stimulating Mannerism Gestures Hypermobile Hyper-responsive
    Startles Aimless Purposeless Overstimulated Repetitive
    Restless Pacing Perseverating Abrupt Agitated
    Active Spontaneous Strong Forceful quick
    Retardation Fluid Slow Latent Delayed
    Lethargic Listless Passive Tentative

    HELPFUL WORDS TO REMEMBER


    Shows Offers Appears Age-appropriate Seems
    Demonstrates States Situation-appropriate Reports Observed
    Noted Produces Declines Refuses Resists
    Withdraws Initiates Inconsistent

    COGNITIVE
    Mental State:
    Concentration Comprehension Retention Hallucinations Delusions
    Clear Alert Attention span Aware Perceptive
    Insightful Memory (recent,
    remote)
    Focused Drowsy Dull
    Reality testing Confused Preoccupied Distractible disoriented
    Thought Process:
    Tangential Pressured Rambling Racing thoughts Tracking
    Processing Abstracting Flight of ideas Generalizing Blocked
    Expansive Concrete thinking Grandiose Obsessive Disorganized
    Poverty of thought scattered

    AFFECT
    Flat Blunted Bland Disappointed Dazed
    Controlled Constricted Matter-of-fact Sober Serious
    Placid Self-critical Calm Composed Comfortable
    Self-deprecatory Staring Relaxed Nonchalant Fixed expression
    Depressed Hopeless Dejected Self-effacing Despondent
    Sad Tearful Apprehensive Subdued Unhappy
    Remorseful Lacking energy Guilty Overwhelmed Powerless
    Belligerent Tense Irritable Frustrated Anxious
    Puzzled Scowling Pressured Fearful Frightened
    Agitated Panicky Resentful Angry Sullen
    Hostile Indignant Cheerful Bright Smiling
    Enthusiastic Eager Energetic Motivated Interested
    Animated Happy Spontaneous Exhilarated Euphoric
    Elated Labile
    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
    Follows
    demonstrations
    Needs cuing Needs clarification
    Needs repeated directions Needs hands-on
    assist
    Learns quickly Retains instructions
    Follows (1-2-or3) step
    directions
    Use of Time:
    Sets goals Works intermittently Utilizes time well Plans ahead Scattered
    Slow to get started Organized Efficient Irregular attendance Productive
    Works steadily Realistic planning Works slowly Hurried Skips steps
    Choice of Activity:
    Indecisive Hesitant Takes initiative Ambivalent Resistant
    Quickly engages Apathetic Slow to engage Chooses familiar
    activity
    Indifferent
    Unrealistic choice Seeks challenging
    activity
    Decisive Selects (type of
    activity)
    Creative, repetitive
    Detailed, short term
    Approach to Activity:
    Patient Persistent Persevering Tolerates frustration Thorough
    Eager Interested Follows through Orderly Neat
    Compulsive Tolerates delays Accurate Careful Cautious
    Recognizes mistakes Impulsive Reckless Careless Use of judgment
    Problem solving Quality of work Seeks quick results Quick gratification Disregards mistakes
    Unaware of mistakes
    Independence/Dependence:
    Responsible Seeks direction Needs reminding Competent Independent
    Self-reliant Accepts direction Seeks reassurance Refuses direction Teaches others
    Debates suggestions Disregards direction Self-sufficient

    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
    fringe)
    Eye contact (direct, occasional, elusive)
    Awareness of social/physical boundaries Group skills: parallel, competitive, cooperative
    Body posture: open, closed, accessible Verbal/nonverbal

    Selective interactions (peers, staff, men, women, young,


    old)
    Speech patterns (rapid, forced, spontaneous, latent)
    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

    You might also like

    pFad - Phonifier reborn

    Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

    Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


    Alternative Proxies:

    Alternative Proxy

    pFad Proxy

    pFad v3 Proxy

    pFad v4 Proxy