Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
or reason for visit; relevant history and examination of findings; clinical impression
or diagnosis; plan of care; identification of appropriate risk factors; date; and legible
identification of the health care professional.
The Manual references time frames: “Each entry in the record is completed (including
authentication) within the time frames delineated by the facility’s medical staff
bylaws, rules, and regulations.” Public health nurses need to be knowledgeable of,
and adhere to, their local facilities’ policies regarding time frames.
Documentation has to occur in a timely fashion, usually at the end of the workday.
In some cases, public health nurses deliver service in the field and do not return to
the office until the next business day; in these cases, documentation must happen
within 24 business hours of the service delivered. Delaying documentation leads to
incomplete or inaccurate information.
In addition to incomplete reporting, delayed documentation can create a gap in service
and possible harm to a patient. For example, let’s say a patient receives service
on Monday from a public health nurse who does not document the service on the day
it occurred. Then, on Tuesday, an emergency happens and a different provider gives
service to the same patient without knowing what was provided on Monday because
Monday’s service was not recorded yet in the patient’s record. This delayed documentation
creates a health risk for the patient and a potential legal liability for the
Indian Health Service if the patient experiences a negative outcome. Another negative
scenario would be that medications or tests ordered for a patient are not delivered
or performed in a timely manner because documentation was not made on the
day of service. This would also create a potential health risk and legal liability.
In regards to billing for PHN services, timeliness of documentation is crucial to support
the processing of collection and to seek immediate reimbursement payments.
Documentation must be accurate to avoid inappropriate billing practices and the potential
for negative financial legal consequences, such as a facility having to repay
fees. Therefore, every effort must be made to ensure that PHN documentation is accurate
and timely.
Remember: if a service was not documented, then the overwhelming
presumption is that the service was not provided.
The American Nurses Association’s Nursing: Scope and Standards of Practice provides
nurses, regardless of specialty, with a scientific process in providing nursing
care. Using the nursing process as a tool in documenting patient care aligns with the
Indian Health Service’s Health Information Management guidelines and is a best
practice for managing documentation risk.
Page 1-4