Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: 1. Degree of severity 2. Type or kind 3. Duration COLOR: 1. Colorless 2. Normal urine 3. Resembling clay 4. Looks same as tar 5. Similar to blood COMA: 1. Slight response to painful stimuli 2. No response to painful stimuli CONSCIOUSNESS: 1. Fully conscious, aware of person, place and time 2. Unconscious but can be aroused 3. Forgetful of behavior or surroundings CONSISTENCY: 1. Retains its shape 2. Watery 3. Thick, sticky or glue-like 4. Containing or resembling mucus Suggested terms to use: 1. Severe, moderate or slight 2. Fever, nervous 3. Protracted, persistent, of short duration 1.Clear 2.Amber 3.Clay colored 4.Tarry 5.Blood tinged 1.Semi-comatose 2.Comatose 1.Fully conscious, alert and oriented x3 2.Stuporous 3.Amnesic 1.Formed 2.Liquid 3.Concentrated, tenacious 4.Mucoid Home Health Agency Nursing Manual J-15