Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: GUMS: 1. Inflammation of the gums 2. A gum boil 3. Pulling away from the teeth 4. Bleeding when pressure is applied HAIR: 1. Clean, good appearance 2. Unclean, coarse 3. Uncombed, neglected 4. Not normal color HALLUCINATION: 1. Of hearing 2. Of sight 3. Of smell HANDS: 1. Dirty, rough, nails broken 2. Abnormally large 3. Fingers square in shape 4. Show good care 5. Wet 6. Dry 7. Hot 8. Cold 9. Shaking continuously HEAD: 1. Forehead 2. Region over temple 3. Back of head 4. Having a large head 5. Base of skull 6. Having a small head Suggested terms to use: 1. Gingivitis 2. Parulis 3. Receding, shrunken 4. Bleeding 1. Clean, glossy 2. Greasy, coarse 3. Tangled, neglected 4. Bleached, dyed 1. Auditory hallucination 2. Visual hallucination 3. Olfactory hallucination 1. Show lack of care 2. Massive 3. Clubbed fingers 4. Well kept 5. Moist 6. Dry 7. Hot 8. Cold 9. Trembling 1. Frontal region 2. Temporal region 3. Occipital region 4. Macrocephalous 5. Basilar 6. Microcephalous Home Health Agency Nursing Manual J-20