Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: HEARTBEAT: 1. Irregular heartbeat 2. Slowness of heartbeat 3. Fast heartbeat HIVES: 1. Hives 2. Itching JOINTS: 1. Bending 2. To straighten 3. Turn downward 4. Turn upward 5. Revolve around 6. Move away from median line 7. Move toward median line 8. A stiff joint 9. Inflammation of joint 10. Wrenching of a joint LEGS: 1. Thigh to knee area 2. Knee to ankle area LICE: 1. On head, body, pubis 2. Condition of having lice LIPS: 1. Pale, colorless 2. Blue in color 3. Presence of tiny cracks 4. Fever blisters present Suggested terms to use: 1. Arrhythmia 2. Bradycardia 3. Tachycardia 1. Urticaria 2. Pruritus 1. Flexion 2. Extension 3. Pronation 4. Supination 5. Rotation 6. Abduction 7. Abduction 8. Ankylosis 9. Arthritis 10. Sprain 1. Upper leg 2. Lower leg 1. Pediculi 2. Pediculosis 1. Pale 2. Cyanotic 3. Fissured, cracked 4. Herpes simplex Home Health Agency Nursing Manual J-21