Policy Manual sample

MDT Home Health Care Agency, Inc. POLICY ON PATIENT ASSESSMENT NURSING & THERAPY SERVICES The evaluation assessment will be performed on patients referred for services and documented in patient records. The assessment is based on patient need or perceived need and addresses physical and functional status. In accordance with the policy of MDT Home Health Care Agency, Inc. any nursing and therapy services offered by the agency directly or under arrangement are given by or under the supervision of a qualified registered nurse and registered therapist in accordance with the Physician’s Plan of Care. The evaluation assessment will be documented whether services continue or not. The assessment should be appropriate to the patient diagnosis and age. The assessment includes, but is not limited to: Patient information: • Patient demographics The environmental component: • Identification of safety and health hazards • Presence of adequate living arrangements (no heat, electricity or water) • Home environmental assessments, which include, the potential for safety and security hazards (e.g., throw rugs, furniture layout, bathroom safety, cluttered stairways and blocked exits, unsecured doors, lack of smoke detectors, and fire risks, oxygen use precautions) Functional limitations component: • The patient's ability to ambulate • Documentation of all functional limitations • Documentation of ability to complete Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) that include: • Bathing • Dressing • Feeding • Toileting • Transferring • Ambulation • Use of telephone • Shopping • Meal preparation • Housework • Money management • Ability to take medication, as appropriate A complete pain and symptom assessment is conducted at the time of admission based on policies and procedures and/or protocols for assessment and management of pain. The assessment includes, but is not limited to: • History of pain and its treatment (including non-pharmacological and pharmacological treatment) • Characteristics of pain, such as: • Intensity of pain (e.g., as measured on a standardized pain scale) • Descriptors of pain (e.g., burning, stabbing, tingling, aching) • Pattern of pain (e.g., constant or intermittent) • Location and radiation of pain • Frequency, timing and duration of pain • Impact of pain on quality of life (e.g., sleeping, functioning, appetite, and mood) • Factors such as activities, care, or treatment that precipitate or exacerbate pain • Strategies and factors that reduce pain Home Health Agency - - Skilled Professional Services C-6