Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
5.2 Verify Order
The public health nurse should verify that there is a patient-specific standing order
(EHR consult from the medical provider to the public health nurse, a medication order,
or a text order) on the patient’s chart and a PHN department policy to support
the action. Consults are done by electronically receiving the consult and documenting
the consulting provider and the date when consult was received on the Text Integration
Utility (TIU) note template.
Paper referrals may be handled in one of two ways: the consult may be entered by
the director of PHN (or designated representative) for tracking or a paper referral
log can be kept for all outside providers. The paper referral should be filed in the
medical record and referenced in the TIU note template when documenting care for
the patient.
Another way to verify an order is for the public health nurse to verify that she or he
has a non-patient-specific medical standing order or protocol and a supporting PHN
department policy to support her or his performing the action.
Medical standing orders only apply to licensed public health
nurses within the PHN department, not to ancillary PHN department
staff (health technicians, certified nursing assistants,
drivers, interpreters, and office assistants). All PHN staff must
have up-to-date competencies.
Directors of PHN must verify that medical standing orders
have been approved by a legal, administrative entity or procedural
body (for example, a governing board or a medical executive).
Directors of PHN must verify that orders are reviewed or
updated on an annual basis.
Indian Health Service Page 5-3