Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: 4. If blood is very apparent 5. Agent used to induce it ENEMAS: 1. To induce a bowel movement 2. To supply nourishment 3. To relieve distention caused by gas 4. To be retained for a brief period of time 5. To aid in fluoroscopic exam EXPECTORATION: 1. A great deal 2. Very little 3. Spitting up blood EYES: 1. Sharpness of vision 2. Yellow in color 3. Puffy, swollen 4. Drooping of lids 5. Motionless, not moving, staring 6. Unusually sensitive to light 7. Double vision 8. Squinting 9. Protrusion of eyeball 10. Inflammation of conjunctiva 11. Dilation of the pupil 12. Contraction of the pupil 13. Near-sighted 14. Far-sighted 15. Sees objects indistinctly Suggested terms to use: 4. Hematemesis 5. Emetic 1. Cleansing enema 2. Nutritive enema 3. A carminative enema (Dade flush) 4. Retention enema 5. Barium enema 1. Profuse 2. Scanty 3. Hemoptysis 1. Visual acuity 2. Jaundiced 3. Edematous 4. Ptosis 5. Fixed 6. Photophobia 7. Diplopia 8. Strabismus 9. Exophthalmos 10. Conjunctivitis 11. Pupil dilated 12. Pupil contracted, pinpoint 13. Myopia 14. Hyperopia 15. Blurred vision Home Health Agency Nursing Manual J-18