Policy Manual sample

MDT Home Health Care Agency, Inc. Factors to be charted: SPEECH: 1. Speaks normally 2. Not understandable 3. Meaningless, wandering 4. Words run together 5. Not heard distinctly 6. Speaks long and well 7. Difficulty in speaking 8. Unable to speak TASTE: 1. As expected, usual 2. Not able to taste normally 3. Like metal TEETH: 1. False teeth 2. Decay of 3. Collection of foul material 4. Other descriptive terms THROAT: 1. Difficulty in swallowing 2. Inability to swallow 3. Other descriptive terms TONGUE: 1. Descriptive terms: Suggested terms to use: 1. Normal speech 2. Incoherent 3. Rambling 4. Slurring 5. Inarticulate 6. Fluent 7. Dysphasia 8. Aphasia 1. Normal 2. Disturbed 3. Metallic 1. Dentures 2. Dental Caries 3. Sordes 4. Natural, notched, decayed, crooked, protruding, loose, irregular, broken 1. Dysphagia 2. Aphagia 3. Red, swollen, inflamed, irritated 1. Pink, moist, dry, cracked, coated, raw, swollen, inflamed, ulcerated Home Health Agency Nursing Manual J-26