Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
PHN department and have an established policy that this provider will review and
enter all outside referrals into the EHR. Other sites have given that authority to the
director of PHN and have a provider assigned each day to co-sign referrals and notes
for the entire PHN department.
Your program will need to have a conversation with the clinical director to establish
a local authentication process for PHN services. How sites choose to authenticate
may vary, but it is recommended that nurses use the following process is to ensure
the necessary documentation.
The public health nurse completes a note that documents the care provided, including
the delegated functions and initiation standing orders. He or she then requests
an additional signature by the ordering provider.
The nurse includes the orders initiated and the justification in the PHN note. Your
clinical applications coordinator can automate this by using TIU objects in the PHN
note template used to create the PHN note or PHN consult note. The TIU objects
automatically populate the note text with the policy orders entered for the visit. Authentication
can be accomplished by the nurse’s requesting an additional signature
by the ordering provider.
Example of an Encounter
TITLE: PHN OFFICE
DATE OF NOTE: JUL 23, 2012@16:16
AUTHOR: ADAN,BEATTY
URGENCY:
ENTRY DATE: JUL 23, 2012@16:16:51
EXP COSIGNER:
STATUS: COMPLETED
PHN IMMUNIZATION ENCOUNTER
---------------------------------------------------------------------------
07/23/12 16:11 00-00-11
30 minutes 0 minutes
DEMO,PATIENT BOSSY, DOB OCT 23,1969 presents to PHN Office for
immunization update.
Indian Health Service Page 5-14