Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
Example of a Non-Patient-Specific Standing Order
All patients should receive an annual influenza vaccine, unless they have a contraindication
to the influenza vaccine. All patients with diabetes should have a HgbA1C
every three months if the previous result was seven or greater or every six months if
previous result was under seven.
The documentation for implementing a standing order may be
the same no matter if it is patient specific or not patient specific.
The nature of the documentation will depend on whether the
PHN service was delivered in a mass community setting (flu
clinic or community screening event, for example) or in an individual
setting (home visit). See Medicare and Medicaid Programs;
Reform of Hospital and Critical Access Hospital Conditions
of Participation—Proposed Rules for guidance on standing
orders development, initiation, and documentation at
http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf.
Indian Health Service Page 5-2