Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: 16. Other descriptive terms 17. Sty on the eyelid FACE: 1. Without color 2. Pink 3. Broken out 4. Black and blue 5. Characteristic expressions FEET: 1. Reddened spots or places caused by pressure or friction 2. Puffy, enlarged, swollen 3. Warm, cold FEVER: 1. Without fever 2. Temperature above normal, feverish 3. Temperature grossly above normal 4. Suddenly elevated temperature 5. Elevated temperature gradually returning to normal FINGERS: 1. Unusually long 2. Coming to a fine point at end 3. Square across end Suggested terms to use: 16.Bright, clear, dull, inflamed, sunken, crossed, bloodshot, burning 17.Hordeolum 1.Pale 2.Flushed 3.Presence of rash, acne 4.Bruised 5.Anxiety, defiance, anger, boredom, happiness, worry, happiness, apathy, sorrow, fear, dissatisfaction 1. Pressure areas present 2. Swollen, edematous 3. Warm, cold 1. Afebrile 2. Tapering 3. Hyperpyrexia 4. Crisis 5. Lysis 1. Long 2. Tapering 3. Clubbed Home Health Agency Nursing Manual J-19