Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
5.3 Labs, Radiology, Consults, and Referrals Standing Order Entry
Non-patient-specific standing orders for labs, radiology, and consults will need to be
entered into the EHR and released by policy so the patient may receive the service.
Point-of-care labs implemented per standing order must be entered with the nature
of order set to “policy.”
Select Patient and Visit, and Set the Visit Context to Indicate the Ordering
Medical Provider
Place the medical provider (physician, physician assistant, or nurse practitioner) in
the Providers for This Encounter field. The public health nurse shoud be highlighted
in the Providers for This Encounter field. The public health nurse provider will then
appear in the visit area of the patient chart, and he or she will be the ordering provider
for any orders. The ordering medical provider becomes the secondary provider,
and the public health nurse becomes the primary provider.
Document the Review and Update of Allergies and Adverse Reactions
Case 1: Let’s say no known allergies are previously documented, and no additional
adverse reactions are reported. Move the mouse pointer over the Adverse Reactions
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