Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
The new data entered in the four cases illustrated above will be stored as visit data
and will be displayed on the health summary.
Please use the help function in EHR for more detailed information on documenting
adverse reactions.
Document the Chief Complaint
You may refer to the standing orders here as part of your justification for implementing
standing orders for lab, radiology, consults, or referrals. The Chief Complaint
frame is shown in the figure. See Section 4.7 above to see how to enter a chief
complaint.
Document the Purpose of Visit
There’s more than one way to set up the purpose of visit (POV). The public health
nurse can select an existing problem or a historical diagnosis and use that to establish
the POV. See figure.
The nurse can also select and enter from a pick list, which is shown below.
Indian Health Service Page 5-9