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Clinical Words to Use in Progress Notes

Salwa Zeineddine

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Effective documentation is a cornerstone of quality patient care. Progress notes serve as a vital tool for clinicians to communicate and collaborate with colleagues, ensuring continuity and providing a comprehensive understanding of a patient's journey.

While progress notes are essential for legal and reimbursement purposes , they also play a crucial role in tracking treatment outcomes and facilitating evidence-based decision-making. To maximize the impact of your care, employing precise and clinically meaningful language is essential.

Using clinical words that accurately capture a patient's symptoms, emotions, and behaviors not only improves communication but also contributes to a more nuanced understanding of their condition.

Precise terminology allows for better collaboration among healthcare professionals, reducing the risk of miscommunication and ensuring appropriate treatment interventions.

As such, this blog post will explore a variety of clinical words to use in your progress notes while providing valuable insights on how to enhance your documentation skills.

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Feeling Stuck? We Got You Covered…

I will be honest, I must admit that I consistently encounter challenges when it comes to crafting my progress notes. I mean, you’ve been there. You know WHAT to write but HOW to write it?

Drawing upon my diverse background of working across various agencies, I humbly acknowledge that I do not possess absolute mastery. However, through diligent effort, I have managed to enhance my proficiency in composing comprehensive notes.

Each one of you probably has a distinct approach to documenting patients’ records, yet I have come to appreciate the following methods as my personal favorites. Hope this can be of help.

Counselor’s Thesaurus

The Counselor's Thesaurus represents a comprehensive compendium of lexicon and eloquent alternatives, meticulously curated to facilitate the discerning clinician in unearthing the precise verbiage, that is in “finding the right words”.

Clinical Words to Describe Affect (Mood or Disposition):

These are words that describe the patient’s underlying experience of emotion or mood, such as: PLACID, PEACEFUL, RESTFUL, TRANQUIL, PREOCCUPIED, ABSORBED, ENGROSSED, LOST IN THOUGHT, PERSONABLE, FRIENDLY, PLEASANT, AFFABLE, AGREEABLE, AMIABLE, PASSIVE, INACTIVE, INERT, UNRESISTANT, ENTHUSIASTIC, ENTHUSED, ARDENT, ZEALOUS, TEARFUL, WEEPY, TEARY, DEPRESSED, DEJECTED, DISPIRITED, DISHEARTENED, CONTROLLED, DETERMINED, REGIMENTED, DISCIPLINED, FLAT, SHALLOW, DULL, SPIRITLESS, BLUNTED, CURT, ABRUPT, BRUSQUE, DETACHED, INDIFFERENT, IMPERSONAL, EUPHORIC, BOUYANT, ELATED, JOYFUL, JOVIAL, MARRY, LIGHTHEARTED, CAREFREE, CHEERFUL, HEARTY, OPTIMISTIC, SMILING, PLACID, QUIET, SOBER, SEDATE, SERIOUS, HOPELESS, DESPERATE…

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Clinical words to describe behavior:.

RECKLESS, IRRESPONSIBLE, RASH, IMPRUDENT, IMPETUOUS, IMPULSIVE, EXCITABLE, ROUSING, HASTY, HURRIED, ABRUPT, UNEXPECTANT, RESTLESS, UNEASY, SPONTANEOUS, SELF-POSSESSED, OVER-CAUTIOUS, SLUGGISH, LETHARGIC, ORGANIZED…

Clinical Words to Describe Cognition (Thought Process):

These refer to both conscious and unconscious processes used to accumulate knowledge such as perceiving, recognizing, conceiving, and reasoning. Examples of words that can be included in your notes: JUDGEMENT, PROBLEM-SOLVING, DECISION MAKING, GOAL SETTING, COMPREHENSION, MEMORY…

Clinical Words to Describe Orientation:

Orientation refers to one’s awareness of the self, the time, the place, and the person one is talking to. Some clinical words that can be used to describe orientation are: FORGETFUL, CONFUSED, DISORIENTED, ORIENTED, DISTRACTIBLE, DETACHED, DISTANT…

Clinical Words to Describe Speech:

Speech can be characterized by an array of descriptors encompassing its multifaceted nature:

• Quantity of speech: This facet delves into the manner in which an individual engages in communication, encompassing traits such as being talkative, spontaneously expressive, expansively communicative, or experiencing paucity or poverty of speech, where minimal expression is observed.
• Rate of speech: This aspect pertains to the tempo at which speech is delivered, encompassing variations that range from rapid and hurried to leisurely and deliberate, or adhering to a normative cadence or experiencing a sense of pressure during speech.
• Volume (tone) of speech: This dimension relates to the auditory qualities of speech, encompassing a spectrum of attributes such as loudness, softness, monotonousness, weakness, or strength in vocal delivery.
• Fluency and rhythm of speech: This facet delves into the smoothness and rhythmic patterns present in speech, encompassing characteristics such as slurred speech, clarity, the presence of appropriately placed inflections, hesitancy, well-articulated delivery, or instances of aphasia.

More on Terminology… Applied to The SOAP Template

To enhance the precision and clarity of your progress notes , it is crucial to employ a variety of clinical words that capture the nuances of a patient's mental health condition. By incorporating effective clinical words, you can provide a comprehensive description of the patient's symptoms, emotions, cognitive functioning, etc. in each of the four sections of the most commonly used SOAP note template. Let's explore some examples of how this be achieved.

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Examples of clinical words to use in the subjective section:, a. symptom description:.

Agitation : Agitation refers to a state of restlessness, increased motor activity, and difficulty sitting still. It is often associated with conditions such as anxiety , mania, or substance withdrawal. Documenting such symptoms helps convey the patient's level of psychological distress and can inform treatment decisions, such as the need for medications to address underlying anxiety or manic symptoms.

Anhedonia : Anhedonia describes the inability to experience pleasure or a diminished interest in activities that were previously enjoyable. It is commonly observed in depression or certain psychotic disorders. By noting such conditions in progress notes using the proper terminology, clinicians can track the patient's response to treatment interventions and gauge the effectiveness of therapeutic strategies aimed at improving pleasure and engagement in daily activities.

Suicidal Ideation : Suicidal ideation involves thoughts or plans related to self-harm or suicide. Documenting suicidal ideation in progress notes and related signs and symptoms is of utmost importance, as it indicates a need for immediate attention and appropriate intervention to ensure patient safety. This information is vital for collaborative care and can guide treatment decisions, such as hospitalization or adjustments to medication regimens.

b. Emotion and Affect:

Euphoria : Euphoria signifies an exaggerated and elevated mood, often associated with manic episodes in bipolar disorder or substance-induced euphoria. Describing euphoria in progress notes provides insights into the patient's emotional state and can help assess the severity of manic symptoms. It aids in treatment planning, such as considering mood stabilizers or addressing substance misuse.

Dysphoria : Dysphoria represents a profound and persistent state of sadness, dissatisfaction, or unease. It is frequently observed in depression, anxiety disorders, or personality disorders. Properly referring to dysphoria in progress notes helps clinicians assess the severity and chronicity of negative emotions, guide treatment decisions, and monitor the effectiveness of interventions aimed at improving mood and emotional well-being.

Flat Affect : Flat affect denotes a reduced range or absence of emotional expression. It is commonly seen in schizophrenia or other psychotic disorders. Properly documenting flat affect in progress notes provides valuable information about the patient's emotional presentation, facilitating accurate diagnostic impressions and guiding treatment strategies , such as antipsychotic medications or psychosocial interventions.

c. Cognitive Functioning:

Disorganized Thinking : Disorganized thinking refers to difficulties in logical reasoning, coherence, or organization of thoughts. It is often observed in conditions such as schizophrenia or bipolar disorder with psychotic features. A proper description of disorganized thinking in progress notes helps clinicians assess the patient's cognitive impairment, guide diagnostic evaluations, and tailor treatment interventions that target cognitive deficits.

Impaired Insight : Impaired insight indicates a lack of awareness or understanding of one's own mental health condition. It can impede treatment adherence or decision-making abilities. Properly documenting impaired insight in progress notes helps track the patient's level of awareness regarding their illness and informs treatment strategies aimed at promoting insight and treatment engagement.

Poor Concentration: Poor concentration describes difficulties in focusing, sustaining attention, or completing tasks. It is seen in conditions such as attention deficit/hyperactivity disorder (ADHD) or depression. Appropriately noting poor concentration in progress notes helps clinicians assess the impact of cognitive symptoms on daily functioning and guides treatment decisions, such as prescribing stimulant medications or implementing cognitive-behavioral strategies to improve attention and concentration.

To note is that those are only a few examples rather than an extensive list of clinical words that can be used in your notes.

Examples of Clinical Words to Use in the Objective Section:

Vital signs:.

• Tachycardia : Rapid heart rate, often indicative of physiological stress or certain medical conditions.
• Hypotension : Low blood pressure, suggesting reduced perfusion and potential cardiovascular instability.
• Hyperthermia : Elevated body temperature, commonly associated with infection or systemic inflammation.

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Physical assessment:.

• Pallor : Abnormally pale skin tone, suggesting reduced blood flow.
• Edema : Excessive accumulation of fluid in tissues, typically presenting as swelling.
• Crepitus : Audible or palpable crackling sounds or sensations, indicating the presence of gas or air in soft tissues.

Neurological Findings:

a. Level of Consciousness :

• Alert and Oriented : Fully awake, aware, and able to respond appropriately to stimuli.
• Obtunded : Reduced alertness and responsiveness, often associated with central nervous system depression.
• Comatose : Profoundly decreased level of consciousness, with no meaningful response to stimuli.

b. Reflexes:

• Hyperreflexia : Exaggerated reflex responses, potentially indicating an upper motor neuron lesion.
• Hyporeflexia : Diminished reflex responses, suggestive of a lower motor neuron dysfunction.
• Clonus : Repetitive, rhythmic contractions and relaxations of a muscle, typically seen in certain neurological conditions.

c. Behavior and Speech:

• Psychomotor Agitation : Restlessness and excessive movement, often accompanied by rapid speech, seen in conditions such as anxiety or mania.
• Psychomotor Retardation : Slowed movement and reduced responsiveness, commonly observed in depression or certain neurological disorders.
• Pressured Speech : Rapid and non-stop speech, often difficult to interrupt, characteristic of manic or hypomanic episodes.

Diagnostic Findings (Laboratory Results):

• Leukocytosis : Elevated white blood cell count, indicating an inflammatory or infectious process.
• Hyponatremia : Low sodium levels in the blood, potentially pointing to fluid imbalances or certain medical conditions.
• Hyperglycemia : High blood sugar levels, frequently associated with diabetes or stress-related conditions.

Examples of Clinical Words to Use in the Assessment and Plan Sections:

• acknowledged the client’s need for improvement in…
• allowed the client to openly express…
• asked the client to be mindful of…
• clarified the expectations for…
• collaborated on/with…
• discussed the client’s current behavior, coping skills, triggers, and treatment plan.
• encouraged the client to express/use mindfulness/make alternative behavioral choices about…
• Educate: Provide information about the patient's diagnosis, treatment options, and self-care strategies.
• Teach: Offering guidance and skills training to enhance coping mechanisms or symptom management.
• Inform: Communicating relevant knowledge about the patient's condition, prognosis, or potential treatment outcomes.
• Cognitive Restructuring: Employing cognitive-behavioral techniques to identify and modify negative or distorted thought patterns.
• Interpersonal Therapy: Focusing on improving interpersonal relationships and resolving conflicts to alleviate symptoms.
• Mindfulness-Based Interventions: Incorporating mindfulness practices to enhance self-awareness and reduce emotional distress.
• Validated: Affirming and acknowledging the patient's experiences, emotions, and struggles.
• Empathized with: Demonstrating understanding and compassion towards the patient's challenges and concerns.
• Actively Listened: Providing undivided attention and receptiveness to the patient's thoughts, feelings, and concerns.
• Consult: Seeking advice or expertise from a specialist in a particular field related to the patient's condition.
• Refer: Directing the patient to another healthcare professional or specialty service for further evaluation or treatment.

Final Thoughts:

We, at Mentalyc , strive for excellence. So, here’s a piece of advice if your goals align with ours. Your progress notes should strike a balance between objective observations and subjective experiences. While objectivity provides measurable and observable information, subjectivity acknowledges the patient's individual experience and perspective. Combining both elements enhances the comprehensiveness of progress notes.

Consider the following strategies while crafting notes:

Objective Language:

• Use standardized rating scales or measurement tools to quantify symptom severity, such as the Hamilton Rating Scale for Depression or the Brief Psychiatric Rating Scale.
• Document observable behaviors, such as changes in sleep patterns, appetite, psychomotor activity, or social interaction.
• Incorporate relevant laboratory findings, imaging results, or diagnostic assessments to support clinical assessments and treatment decisions.

Subjective Language:

• Quote the patient's own words or descriptions of their experiences, providing insights into their subjective perspective.
• Use empathetic and validating language to acknowledge and reflect on the patient's emotional struggles.
• Employ descriptive language or metaphors to capture the patient's subjective experiences, facilitating a deeper understanding of their inner world.

Avoid Jargon and Stigma:

While clinical language is essential in psychiatric progress notes , it is crucial to strike a balance and avoid excessive jargon or stigmatizing terminology. Ensure that the language used is accessible and understandable to all healthcare professionals involved in the patient's care. Avoid stigmatizing or judgmental terms that may perpetuate stereotypes or hinder effective communication. Choose language that promotes empathy, respect, and dignity for the patient.

Ask for Help:

Mentalyc offers a sophisticated solution that empowers you to meticulously shape your progress notes by leveraging our extensive range of templates and assessment tools. Renowned as a frontrunner in the field of electronic health records (EHR) for behavioral health specialties, Mentalyc m delivers an intuitive and resilient charting platform designed to fulfill all your requirements while alleviating the weight of documentation. By embracing our innovative system, you can redirect your attention toward what truly holds significance. Embark on this transformative journey by scheduling a demo today or initiating a free trial to witness firsthand how our cutting-edge solutions can enrich your professional practice.

References:

• American Psychological Association. (2010) . Documentation in psychotherapy. American Psychologist, 65(7), 663–673.
• Ward, K. D. (2006) . Documentation: Charting and legal considerations for mental health professionals. Journal of Psychosocial Nursing and Mental Health Services, 44(11), 16–19.
• Green, B. E., & Tuerk, P. (2014) . A clinician's guide to clinical words. Journal of Mental Health Counseling, 36(3), 240-249.
• Sarmiento, I., Connell, M., & Kesten, K. (2016) . Enhancing the quality of mental health progress notes: A systematic review of the literature. Journal of Psychiatric and Mental Health Nursing, 23(1), 68-80.
• Gibson, K. J., & Rhynas, S. J. (2015) . The use of language in psychiatric nursing practice. Journal of Psychiatric and Mental Health Nursing, 22(2), 99-108.

About the author

Salwa Zeineddine is an expert in the mental health and medical field. She has extensive experience in the medical field, having worked as a medical researcher at the American University of Beirut. She is highly knowledgeable about therapist needs and insurance requirements. Salwa is passionate about helping people understand and manage their mental health, and she is committed to providing the best possible care for her patients. She is an advocate for mental health awareness and works to ensure that everyone has access to the resources they need.

Learn More About Salwa

All examples of mental health documentation are fictional and for informational purposes only.

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Tools for the Patient Presentation

The formal patient presentation.

• Posing the Clinical Question
• Searching the Medical Literature for EBM

Sources & Further Reading

First Aid for the Wards

Lingard L, Haber RJ.  Teaching and learning communications in medicine: a rhetorical approach .  Academic Medicine. 74(5):507-510 1999 May.

Lingard L, Haber RJ.  What do we mean by "relevance"? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format . Academic Medicine. 74(10):S124-S127.

The Oral Presentation (A Practical Guide to Clinical Medicine, UCSD School of Medicine)  http://meded.ucsd.edu/clinicalmed/oral.htm

"Classically, the formal oral presentation is given in 7 minutes or less. Although it follows the same format as a written report, it is not simply regurgitation. A great presentation requires style as much as substance; your delivery must be succinct and smooth. No time should be wasted on superfluous information; one can read about such matters later in your admit note. Ideally, your presentation should be formulated so that your audience can anticipate your assessment and plan; that is, each piece of information should clue the listener into your thinking process and your most likely diagnosis."  [ Le, et al, p. 15 ]

Types of Patient Presentations

New Patient

New patients get the traditional H&P with assessment and plan.  Give the chief complaint and a brief and pertinent HPI.  Next give important PMH, PSH, etc.  The ROS is often left out, as anything important was in the HPI.  The PE is reviewed.  Only give pertinent positives and negatives.  The assessment and plan should include what you think is wrong and, briefly, why.  Then, state what you plan to do for the patient, including labs.  Be sure to know why things are being done: you will be asked.

The follow-up presentation differs from the presentation of a new patient.  It is an abridged presentation, perhaps referencing major patient issues that have been previously presented, but focusing on new information about these issues and/or what has changed. Give the patient’s name, age, date of admission, briefly review the present illness, physical examination and admitting diagnosis.  Then report any new finding, laboratory tests, diagnostic procedures and changes in medications.

The attending physician will ask the patient’s permission to have the medical student present their case.  After making the proper introductions the attending will let the patient know they may offer input or ask questions at any point.  When presenting at bedside the student should try to involve the patient.

Preparing for the Presentation

There are four things you must consider before you do your oral presentation

• Occasion (setting and circumstances)

Ask yourself what do you want the presentation to do

• Present a new patient to your preceptor : the amount of detail will be determined by your preceptor.  It is also likely to reflect your development and experience, with less detail being required as you progress.
• Present your patient at working or teaching rounds : the amount of detail will be determined by the customs of the group. The focus of the presentation will be influenced by the learning objectives of working responsibilities of the group.
• Request a consultant’s advice on a clinical problem : the presentation will be focused on the clinical question being posed to the consultant.
• Persuade others about a diagnosis and plan : a shorter presentation which highlights the pertinent positives and negatives that are germane to the diagnosis and/or plan being suggested.
• Enlist cooperation required for patient care : a short presentation focusing on the impact your audience can have in addressing the patient’s issues.

Preparation

• Patient evaluation : history, physical examination, review of tests, studies, procedures, and consultants’ recommendations.
• Selected reading : reference texts; to build a foundational understanding.
• Literature search : for further elucidation of any key references from selected reading, and to bring your understanding up to date, since reference text information is typically three to seven years old.
• Write-up : for oral presentation, just succinct notes to serve as a reminder or reference, since you’re not going to be reading your presentation.

Knowledge (Be prepared to answer questions about the following)

• Pathophysiology
• Complications
• Differential diagnosis
• Course of conditions
• Diagnostic tests
• Medications
• Essential Evidence Plus

Template for Oral Presentations

Chief Complaint (CC)

The opening statement should give an overview of the patient, age, sex, reason for visit and the duration of the complaint. Give marital status, race, or occupation if relevant.  If your patient has a history of a major medical problem that bears strongly on the understanding of the present illness, include it.  For ongoing care, give a one sentence recap of the history.

History of Present Illness (HPI)

This will be very similar to your written HPI. Present the most important problem first. If there is more than one problem, treat each separately. Present the information chronologically.  Cover one system before going onto the next. Characterize the chief complaint – quality, severity, location, duration, progression, and include pertinent negatives. Items from the ROS that are unrelated to the present problem may be mentioned in passing unless you are doing a very formal presentation. When you do your first patient presentation you may be expected to go into detail.  For ongoing care, present any new complaints.

Review of Systems (ROS)

Most of the ROS is incorporated at the end of the HPI. Items that are unrelated to the present problem may be briefly mentioned.  For ongoing care, present only if new complaints.  

Past Medical History (PMH)

Discuss other past medical history that bears directly on the current medical problem.  For ongoing care, have the information available to respond to questions.

Past Surgical History

Provide names of procedures, approximate dates, indications, any relevant findings or complications, and pathology reports, if applicable.  For ongoing care, have the information available to respond to questions.

Allergies/Medications

Present all current medications along with dosage, route and frequency. For the follow-up presentation just give any changes in medication.  For ongoing care, note any changes.

Smoking and Alcohol (and any other substance abuse)

Note frequency and duration. For ongoing care, have the information available to respond to questions.

Social/Work History

Home, environment, work status and sexual history.  For ongoing care, have the information available to respond to questions.

Family History Note particular family history of genetically based diseases.  For ongoing care, have the information available to respond to questions.

Physical Exam/Labs/Other Tests

Include all significant abnormal findings and any normal findings that contribute to the diagnosis. Give a brief, general description of the patient including physical appearance. Then describe vital signs touching on each major system. Try to find out in advance how thorough you need to be for your presentation. There are times when you will be expected to give more detail on each physical finding, labs and other test results.  For ongoing care, mention only further positive findings and relevant negative findings.

Assessment and Plan

Give a summary of the important aspects of the history, physical exam and formulate the differential diagnosis. Make sure to read up on the patient’s case by doing a search of the literature. 

• Include only the most essential facts; but be ready to answer ANY questions about all aspects of your patient.
• Keep your presentation lively.
• Do not read the presentation!
• Expect your listeners to ask questions.
• Follow the order of the written case report.
• Keep in mind the limitation of your listeners.
• Beware of jumping back and forth between descriptions of separate problems.
• Use the presentation to build your case.
• Your reasoning process should help the listener consider a differential diagnosis.
• Present the patient as well as the illness .
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How to present clinical cases

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• Ademola Olaitan , medical student 1 ,
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Presenting a patient is an essential skill that is rarely taught

Clinical presenting is the language that doctors use to communicate with each other every day of their working lives. Effective communication between doctors is crucial, considering the collaborative nature of medicine. As a medical student and later as a doctor you will be expected to present cases to peers and senior colleagues. This may be in the setting of handovers, referring a patient to another specialty, or requesting an opinion on a patient.

A well delivered case presentation will facilitate patient care, act a stimulus for timely intervention, and help identify individual and group learning needs. 1 Case presentations are also used as a tool for assessing clinical competencies at undergraduate and postgraduate level.

Medical students are taught how to take histories, examine, and communicate effectively with patients. However, we are expected to learn how to present effectively by observation, trial, and error.

Principles of presentation

Remember that the purpose of the case presentation is to convey your diagnostic reasoning to the listener. By the end of your presentation the examiner should have a clear view of the patient’s condition. Your presentation should include all the facts required to formulate a management plan.

There are no hard and fast rules for a perfect presentation, rather the content of each presentation should be determined by the case, the context, and the audience. For example, presenting a newly admitted patient with complex social issues on a medical ward round will be very different from presenting a patient with a perforated duodenal ulcer who is in need of an emergency laparotomy.

Whether you’re presenting on a busy ward round or during an objective structured clinical …

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The Clinical Presentation

• First Online: 01 January 2013

Cite this chapter

• Sergio V. Delgado 3 &
• Jeffrey R. Strawn 4  

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Presenting case material to colleagues requires preparation, whether the presentation is to be made casually during bedside rounds or in the formal environment of a national meeting. It is rewarding when a presentation is well received, particularly because it may prove helpful to other clinicians, allied health professionals, and researchers. Regardless of the setting, the presenter’s goal is to share their knowledge based on observations they have made and lessons they have learned from the case or cases. The most time-consuming aspect of the patient-oriented presentation is collecting and organizing as much information as possible about the patients, their families, and others who were involved in the patients’ care. Once these tasks are complete, the presenter must summarize the information and place it within the context of treatment data and consensus approaches. Tailoring the talk to the audience is also of paramount importance. Different groups will invariably come from different disciplines, and the presentation will need to be tailored to accommodate each audience’s background, interests and goals.

Make everything as simple as possible, but not simpler —Albert Einstein (1879–1955)

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Department of Psychiatry and Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

Sergio V. Delgado

Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA

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Delgado, S.V., Strawn, J.R. (2014). The Clinical Presentation. In: Difficult Psychiatric Consultations. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-39552-9_8

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Synonyms for Healthcare presentation

14 other terms for healthcare presentation - words and phrases with similar meaning.