Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses She or he can also search for a sign, symptom, or diagnosis from the Visit Diagnosis frame, show below. For more details about how to set up the POV, see Section 4.10 above. Document the Activity Time See Section 4.4 above. Enter the Lab Order Document the indication for the study using (a) the clinical indication field for lab orders, (b) the history section for radiology, (c) the reason for requests for consults, or (d) the visit diagnosis based on local policy. Indian Health Service Page 5-10
Documentation and Coding Guidelines for Public Health Nurses The indication represents part of the specified circumstances for the standing order policy initiation. It is usually (a) a problem list item, (b) a purpose of visit entered by a provider previously, or (c) a sign or symptom identified in the chief complaint or nursing assessment. To release nonmedication standing orders by policy, select the Policy radio button in the signature tool dialog box. This allows these orders to be processed by the receiving service, such as laboratory. Indian Health Service Page 5-11
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FOREWORD This manual was written by
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Public Health Nursing Documentation Guidelines - Indian Health ...

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