Public Health Nursing Documentation Guidelines - Indian Health ...

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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 Indian Health Service Page 5-4
Documentation and Coding Guidelines for Public Health Nurses frame and right click. In the pop-up menu, choose Chart Review and then choose No Active Allergies in the submenu as shown in the figure below. Case 2: Let’s say allergies or adverse reactions were previously documented, and no additional adverse reactions are going to be reported. Right click on the Adverse Reactions frame, select Chart Review, and then select Reviewed. See figure. Indian Health Service Page 5-5
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DOCUMENTATION AND CODING GUIDELINES
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FOREWORD This manual was written by
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4.13 Medications ..................
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Intensity of Visits ...............
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Documentation and Coding Guidelines
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Public Health Nursing Documentation Guidelines - Indian Health ...

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