Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
5.4 Medication Standing Orders
Most medication standing orders—two examples are directly observed therapy and
prophylaxis for identified close contacts for a particular communicable disease—
should be placed ahead of time by the medical provider. These are orders for medications
that often require an assessment before administration.
The public health nurse may also receive an EHR consult on an individual patient.
For example, a medical provider asks a public health nurse to change a patient’s
medication or dose due to a medical error or lab result.
Administering medications in clinic fall under “incident to”
rules for Medicare billing. See section 50 of Chapter 15 of the
Medicare Benefit Policy Manual at
http://www.cms.gov/manuals/Downloads/bp102c15.pdf.
The public health nurse must verify that he or she has a current policy or protocol to
follow, such as a policy on delivery and administration of sexually-transmitteddisease
prophylaxis to partners.
The public health nurse places the order for the medication in
the EHR and chooses “hold until signed.” Once the medication
order is signed by the provider, the public health nurse then
follows the rest of the policy to deliver and administer the medication.
The nurse must document the required assessment and the administration of the
medication, using approved format—SOAP (subjective-objective-assessment-plan) or
SOAPIE (SOAP plus intervention and evaluation)—based on local policy. See Sections
1.1 and 4.12 above for discussions about SOAP and SOAPIE.
Sample Note
The following note is authenticated using the Identify Additional Signer function.
PUBLIC HEALTH NURSING STI CONTACT ENCOUNTER
DATE OF VISIT: 07/23/12 16:11 DEMO,PATIENT BOSSY,OCT 23,1969,00-00-11
AT/TT:30 minutes/0 minutes
LOCATION OF ENCOUNTER: HOME
REFERRAL RECEIVED: 20-Jul-2012FROM:PR PRIMARY PROVIDER
R/T: POSITIVE CHLAMYDIA
Not At Home attempts X 0
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Priority I - PHN Level of Care
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SUBJECTIVE
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Indian Health Service Page 5-16