Policy Manual sample

MDT Home Health Care Agency, Inc. DESCRIPTIVE TERMS COMMONLY USED IN CHARTING Factors to be charted: ABDOMEN 1. Large and extends outward 2. Black and blue marks present 3. Hard, board-like 4. Soft, flabby, flat 5. Hurts when touched 6. Appears swollen, rounded 7. Presence of rash 8. Filled with gas 9. Scars present AREAS OR REGIONS OF THE ABDOMEN 1. Right hypochondriac region 2 Epigastric region 3. Left hypochondriac region 4. Right lumbar region 5. Umbilical region 6. Left lumbar region 7. Right iliac region 8. Hypogastric region 9. Left iliac region AMOUNTS: 1. Large amount 2. Moderate amount 3. Small amount GENERAL APPEARANCE: 1. Thin and undernourished 2. Fat 3. Seems very sick 4. Not very sick Suggested terms to use: 1. Enlarged, protruding 2. Bruised 3. Hard, rigid 4. Relaxed, flaccid, flat 5. Tender, sensitive 6. Distended 7. Rash present 8. Tympanites 9. Scarified 1.Profuse, copious, free, excessive, measured volume 2.Moderate, usual, measured volume 3.Small amount, scanty, slight, measured volume 1. Emaciated 2. Obese 3. Acutely ill 4. Not acutely ill Home Health Agency Nursing Manual J-11