There's a standardized way to document how tender your patient is to palpation. How does your patient react? You can grade the amount of pain they are in.
When applying static palpation to a patient's joints, muscles, tendons, ligaments or superficial tissue, tenderness can be graded based on the patient's response.
|Grade 1 tenderness (or +1/4 T)||Tenderness with no physical response|
|Grade 2 tenderness (or +2/4 T)||Tenderness with grimace, wince, or flinch|
|Grade 3 tenderness (or +3/4 T)||Tenderness with withdrawal (positive jump sign)|
|Grade 4 Tenderness (or +4/4 T)||Non-noxious stimuli results in patient withdrawal or refusal to be palpated due to pain.|
When charging you should know it is the tender point that you are palpating reproduces the presenting complaint. Also, severity of tenderness is greater on the right or left.
When charging you can use the grading scale such as "the patient demonstrated a great one tenderness." Or, you can write a description. For example, "patient demonstrated the jump sign.