Policy Manual sample

MDT Home Health Care Agency, Inc. POLICY FOR NURSES NOTES, HINTS AND PATIENT’S TRAINING AL Clinical notes MUST INCLUDE: Specific times for each entry and date. All nursing/therapy interventions, modalities and observations. Reasons for PRN and STAT drugs. Signs and symptoms displayed by patients. Complications and actions taken. Follow-up (doctor called, time, etc.) Any further comments that communicate patient information. Cut down on excess verbalization. Be specific and concise. Read notes from previous shifts and report on any follow-up. PHYSIOLOGICAL RESPONSES: Observe, and intervene as necessary, changes in patient's: 1.Appearance 3. Level of consciousness 2. Vital signs 4. Verbal behavior ACTIVITIES OF DAILY LIVING: Be specific, i.e. not just "a.m. care". OOB ad lib, walker in hall times 2, bath with assistance, etc. BODY MECHANICS: Maintain proper body alignment when positioning, physical therapy, etc. Check traction, K footboards, slings, etc. TEACHING, TRAINING, PATIENT’S/CAREGIVER EDUCATION: Patient Education (and/or family) is an active and interdisciplinary process, aimed at producing an observable change in a patient's behavior or attitudes, and ultimately resulting in an improved outcome for the patient. It is the Policy of our Agency, that our employees may instruct our patients according Nurse/Therapist evaluation of the Patients response to instructions given, including reenforcements of instructions if the field employee evaluate that the patient ability to understand the teachings is not satisfactory, the Teaching must supervising and counseling the patient and familymembers regarding the nursing/therapy care needs, including but not limited to plan of care, medication regimen, use, side effects, treatment program, disease process, sign and symptoms, safety measures, universal precautions and other related problems of the patient at home, proper use, safety hazards, and infection control issues related to the use and maintenance of any equipment provided, how to notify the Agency of problems, concerns and complaints, Emergency preparedness information, (this education includes information regarding individuals planning for emergencies/disasters such as Evacuation plans, medications, food/water, important documents, care for pets, if applicable). Careful assessment of the patients learning ability and needs forms the cornerstone of effective patient education and must precede any teaching. The assessment must also consider the patient's emotional readiness to learn. The teaching plan should include specific patient outcomes that have been agreed upon with the patient, and the teaching strategies that will best help meet the selected outcomes. Our Agency goal for full patient/caregiver learning after the complete training for each subject was provided, is a maximum of 3 services days, the employee must verify/measure the ability/response of the patient to training, asking questions regarding training provided, such as medications side effects, disease sign and symptoms, etc. If the teaching is unsuccessful, it may be necessary to modify or revise the process being used. If the patient outcomes are not accomplished, it may be necessary to reassess, revise the plan or reimplement. One goal Home Health Agency Nursing Manual J-2