Table 2-1: Documentation: Descriptive Words ... - Child Life Council

MOTORPosture:Table 2-1: Documentation: Descriptive WordsRuth Herold, CTRS and Kristin Ogren, OTR/LOverlake Hospital and Medical Center, Bellevue, WATense Rigid Slouching Slumped Head downRelaxedOpen/closedMovements:Coordination Balance Gait Motor planning Gross motorFine motor Dexterity Eye-hand coordination Tremor SpasmJerking Handwriting (quality) Dyskinesia Rocking Nervous habitSelf-stimulating Mannerism Gestures Hypermobile Hyper-responsiveStartles Aimless Purposeless Overstimulated RepetitiveRestless Pacing Perseverating Abrupt AgitatedActive Spontaneous Strong Forceful quickRetardation Fluid Slow Latent DelayedLethargic Listless Passive TentativeHELPFUL WORDS TO REMEMBERShows Offers Appears Age-appropriate SeemsDemonstrates States Situation-appropriate Reports ObservedNoted Produces Declines Refuses ResistsWithdraws Initiates InconsistentCOGNITIVEMental State:Concentration Comprehension Retention Hallucinations DelusionsClear Alert Attention span Aware PerceptiveInsightfulMemory (recent, Focused Drowsy Dullremote)Reality testing Confused Preoccupied Distractible disorientedThought Process:Tangential Pressured Rambling Racing thoughts TrackingProcessing Abstracting Flight of ideas Generalizing BlockedExpansive Concrete thinking Grandiose Obsessive DisorganizedPoverty of thoughtscatteredAFFECTFlat Blunted Bland Disappointed DazedControlled Constricted Matter-of-fact Sober SeriousPlacid Self-critical Calm Composed ComfortableSelf-deprecatory Staring Relaxed Nonchalant Fixed expressionDepressed Hopeless Dejected Self-effacing DespondentSad Tearful Apprehensive Subdued UnhappyRemorseful Lacking energy Guilty Overwhelmed PowerlessBelligerent Tense Irritable Frustrated AnxiousPuzzled Scowling Pressured Fearful FrightenedAgitated Panicky Resentful Angry SullenHostile Indignant Cheerful Bright SmilingEnthusiastic Eager Energetic Motivated InterestedAnimated Happy Spontaneous Exhilarated EuphoricElatedLabile© 1990 Idyll Arbor, Inc. for ©1986 Herold and Ogren

TASK PERFORMANCEFollowing Directions:Follows written directionsNeeds repeated directionsTable 2-1 (CONT.): Documentation: Descriptive WordsRuth Herold, CTRS and Kristin Ogren, OTR/LOverlake Hospital and Medical Center, Bellevue, WAFollows verbaldirectionsNeeds hands-onassistFollowsdemonstrationsLearns quicklyNeeds cuingRetains instructionsNeeds clarificationFollows (1-2-or3) stepdirectionsUse of Time:Sets goals Works intermittently Utilizes time well Plans ahead ScatteredSlow to get started Organized Efficient Irregular attendance ProductiveWorks steadily Realistic planning Works slowly Hurried Skips stepsChoice of Activity:Indecisive Hesitant Takes initiative Ambivalent ResistantQuickly engages Apathetic Slow to engage Chooses familiar IndifferentactivityUnrealistic choiceSeeks challenging DecisiveSelects (type of Creative, repetitiveactivityactivity)Detailed, short termApproach to Activity:Patient Persistent Persevering Tolerates frustration ThoroughEager Interested Follows through Orderly NeatCompulsive Tolerates delays Accurate Careful CautiousRecognizes mistakes Impulsive Reckless Careless Use of judgmentProblem solving Quality of work Seeks quick results Quick gratification Disregards mistakesUnaware of mistakesIndependence/Dependence:Responsible Seeks direction Needs reminding Competent IndependentSelf-reliant Accepts direction Seeks reassurance Refuses direction Teaches othersDebates suggestions Disregards direction Self-sufficientSOCIALExpressive Joking Congenial Engaging AgreeableTactful Articulate Gracious Talkative WarmOpen Self-disclosing Assertive Spontaneous OutspokenCooperative Considerate Sensitive Sympathetic Care-takingDoting Tolerant Supportive Concerned IndifferentApathetic Isolating Sense of humor Solitary SuperficialReserved Self-focused Guarded Suspicious WithdrawnArgumentative Seclusive Detached Passive Engages in power struggleShy Timid Deferring Condescending SubmissiveTentative Dependent Ingratiating Distrustful DocileCompliant Watchful Aggressive Threatening DominatingForceful Intrusive Sarcastic Critical ProvocativeCynical Flippant Competitive BoastfulSocial Behaviors:Placement of seating in group (isolates, dominates, on Eye contact (direct, occasional, elusive)fringe)Awareness of social/physical boundariesGroup skills: parallel, competitive, cooperativeBody posture: open, closed, accessibleVerbal/nonverbalSelective interactions (peers, staff, men, women, young, Speech patterns (rapid, forced, spontaneous, latent)old)Tone of voice (monotone, inaudible, loud, soft)Quality of groomingRole of patient in groupResponse of peers to patientPatient response to authority© 1990 Idyll Arbor, Inc. for © 1986 Herold and Ogren