Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: DIZZINESS: 1. Dizziness 2. Fainting DRAINAGE: 1. Watery, from nose 2. Containing pus 3. Bloody 4. Consists of feces 5. Of lymphatic fluid 6. Contains mucus and pus 7. Tough, sticky 8. From vagina (after delivery) DRESSINGS: 1. A second dressing added to first 2. Dressing removed, another one applied 3. Drains partially removed 4. Drains cut off DROP: 1. A drop 2. Drops EARS: 1. Wax in the ears 2. Ringing in the ears 3. Abnormal in shape EMESIS: 1. Produced by effort of patient 2. Ejected a few feet distant 3. If blood is slightly noticeable Suggested terms to use: 1. Vertigo 2. Syncope 1. Coryza 2. Purulent 3. Sanguineous 4. Fecal 5. Serous 6. Mucopurulent 7. Tenacious 8. Lochia 1. Dressing reinforced 2. Dressing changed 3. Drains advanced 4. Drains shortened 1. Gtt 2. Gtts 1. Cerumen 2. Tinnitus aurium 3. Deformed 1. Induced 2. Projectile 3. Blood tinged Home Health Agency Nursing Manual J-17