Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: 4. Gluteal area 5. Sway back 6. Hump back BATHS 1. Given when pt. admitted 2. All-inclusive bath 3. Including face, arms, back, axilla, genitals 4. Special baths 5. Taken in tub 6. Taken in bed by patient BELCH: 1. Belching BLEEDING: 1. Spurting of blood 2. Very little 3. Nosebleed 4. Blood in vomits 5. Blood in urine 6. Spitting of blood 7. When bleeding is stopped BLISTER: 1. Blister BLOOD PRESSURE 1. B.P. 120/74 B.M.R.: 1. Basal Metabolic rate BREAST: 1. Inflammation of 2. Each of same size 3. Satisfactory in appearance 4. Nipple(s) always depressed Suggested terms to use: 4. Buttocks 5. Lordosis 6. Kyphosis 1. Admission bath 2. Complete bath 3. Partial bath 4. Name of bath (e.g. Sitz) 5. Tub bath 6. Self bath1. Basal 1. Eructation 1. In spurts 2. Oozing 3. Epistaxis 4. Hematemesis 5. Hematuria 6. Hemoptysis 7. Hemostasis 1. Vesicle 1. B.P. 120/74 1. B.M.R. 1. Mastitis 2. Of equal size 3. Developed normally 4. Inverted nipples Home Health Agency Nursing Manual J-13