Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: CONVULSION: 1. Continuous shaking which stops in 15minutes 2. Shaking with intervals of rest 3. Begun without warning (aura) 4. Unending shaking COUGH: 1. Coughs all the time 2. Coughing over long period 3. Coughs up material 4. Occurring in spasms 5. Coughs quite often 6. Cough that does not produce material 7. With characteristic "whoop" on inspiration 8. Occurs in paroxysms or attacks 9. Coughing up bloody material 10. Other self-explanatory terms used to describe a cough DECAY: 1. Of teeth 2. Of tissue DEFECATION: 1. Bowel movement (material) 2. Bowel movement (act of) 3. Excessive defecation 4. Dark brown liquid stool 5. Gray colored stool 6. Formed, with hardened feces Suggested terms to use: 1. Tonic seizure 2. Clonic seizure 3. Sudden onset 4. Status epilepticus 1. Continuous cough 2. Persistent cough 3. Productive cough 4. Spasmodic cough 5. Frequent cough 6. Non-productive cough 7. Whooping cough 8. Paroxysmal cough 9. Hemoptysis 10. Tight, loose, deep, dry, hacking, harsh, painful, rasping, explosive 1. Dental caries 2. Necrosis 1. Feces, stool 2. Defecation 3. Diarrhea 4. Liquid stool 5. Clay colored stool 6. Hardened-formed stool Home Health Agency Nursing Manual J-16