Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: LUNGS: 1. Abnormal sounds in lung MEDICINE (administration of): 1. By mouth 2. By rectum 3. Breathing in 4. Under the skin 5. Within the skin 6. Within muscle 7. Within the vein 8. Pouring into a body cavity 9. Placing on (top of) the skin NAILS: 1. Blue in color 2. Other descriptive terms ODOR: 1. Pleasant 2. Like ammonia 3. Like fruit 4. Very unpleasant 5. Of a particular type PAIN: 1. Great pain 2. Some pain 3. Coming in seizures 4. Spreading to distant parts 5. Started all at once 6. Hurts worse when moved 7. Painful if touched Suggested terms to use: 1. Rales (coarse, fine), wheezes, rhonchi 1. Orally 2. Rectally 3. Inhalation 4. Subcutaneous 5. Intradermal 6. Intramuscular 7. Intravenous 8. Instillation 9. Topical 1. Cyanotic 2. Brittle, clean, torn, manicured 1. Aromatic 2. Ammoniacal 3. Fruity 4. Offensive, foil 5. Characteristic of 1. Severe 2. Slight 3. Paroxysmal 4. Radiating 5. Sudden onset 6. Increased by movement 7. Tender to touch Home Health Agency Nursing Manual J-22