Public Health Nursing Documentation Guidelines - Indian Health ...

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