Policy Manual sample

MDT Home Health Care Agency, Inc. Legal Aspects of Charting...page 2 VIEWPOINT: Although the system allows freedom of making independent nursing judgements about problems and actions, it does so within a defined framework which helps to guide and support a nurse in problem-solving and decision making. As far as a patient is concerned, nursing care planned for his problems clearly defined and stated is, for instance far superior to "routine post-op care" or "coronary care regimen". Basic elements of Problem-Oriented Charting: 1. Data Base ! Admission history ! Medical history ! Physical exam ! Lab/test results 2. Problem List ! Medical diagnosis ! Nursing problems ! Social and living problems ! Behavioral difficulties ! Abnormal lab findings ! Abnormal physical findings ! Abnormal signs and symptoms ! Health hazards 3. Initial Plans ! Written for each problem ! Includes diagnostic regimen, therapeutic program, patient/family education plan 4. Clinical notes ! Documentation of the patient's status and response to the plan of care Home Health Agency Nursing Manual J-10