Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses The order will show that the order was entered by the nurse on behalf of the provider as a policy order. Point-of-Care Laboratory Testing Standing Order Documentation Point-of-care laboratory screening tests (waived tests) are implemented per medical standing order. The nurse entering the point-of-care lab on behalf of the provider needs to set the Nature of Order field in the Lab Point-of-Care Data Entry Form to “Policy,” as in the figure below. Other fields in the entry form should be handled thusly: Ordering Provider Indian Health Service Page 5-12
Documentation and Coding Guidelines for Public Health Nurses If this field is prepopulated, the provider’s name will be displayed in the visit frame of the patient chart. If it is blank, the nurse must enter the ordering medical provider who will receive the notification and will authenticate the order. Test Select the point-of-care test you are entering the results for. Common pointof-care lab tests performed by public health nurses are glucose (HgbA1C), cholesterol, and urine nCG. Collection Date and Time The default setting is the current date and time. If you are entering a late documentation, change this field to the actual date and time of the lab. Sign or Symptom Choose from the drop-down menu (which contains a list of problems and purposes of visit) or search for a sign or symptom. Comment This field is optional. At the end of the form, enter the test result, move to next field, and then click Save. You cannot edit your point-of-care lab entry once it has been saved. Carefully review the information before clicking Save. If you entered something in error, contact your laboratory supervisor. Authentication of an Implemented Order Orders for services and delegated functions must be authenticated by the ordering medical provider. Authentication is performed by a physician, nurse practitioner, midwife, or physician assistant. When orders are not signed by the provider—as when orders are released by policy—the nurse must enter medical documentation (for example, a progress note) of the orders initiated, the indication for the orders, and any assessment required. For standing orders, this documentation is done after the fact. It is important to meet Centers for Medicare and Medicaid Services (CMS) conditions of participation by ensuring the provider assigned is readily available during the hours of the PHN activity. Some sites have a primary provider assigned to the Indian Health Service Page 5-13
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DOCUMENTATION AND CODING GUIDELINES
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FOREWORD This manual was written by
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