Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: SKIN (cont'd) 13. Other descriptive terms: 14. Indicate presence of: 15. Pimples 16. Blister 17. Pimple filled with pus 18. Containing colored areas 19. Wet 20. Scraped 21. Redness of 22. Small ecchymosis of skin 23. Area where skin is rubbed off SLEEP 1. Slept very little 2. Tired when awakens 3. Moans while sleeping 4. Inability to sleep SMOKE: 1. Smokes too much SYMPTOMS: 1. Observed only by patient 2. Observed by someone other than patient 3. A group of symptoms Suggested terms to use: 13. Mottled, discolored, moist, dry, hot, broken, cold, warm, oily, tight, calloused, wrinkled, tanned 14. Rash, abrasion, laceration, insect bite, tumors, acne, scars, ulcers, moles, fissures, abscess 15. Papule 16. Vesicle 17. Pustule 18. Pigmented 19. Moist 20. Abraded 21. Erythema 22. Petechia 23. Abrasion 1. Slept at short intervals 2. Awakens fatigued 3. Sleep disturbed, moaning 4. Insomnia 1. Smokes excessively 1. Subjective (e.g. pain) 2. Objective (e.g. bleeding) 3. Syndrome Home Health Agency Nursing Manual J-25