Public Health Nursing Documentation Guidelines - Indian Health ...

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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 --------------------------------------------------------------------------- Priority I - PHN Level of Care --------------------------------------------------------------------------- SUBJECTIVE --------------------------------------------------------------------------- Indian Health Service Page 5-16
Documentation and Coding Guidelines for Public Health Nurses Chief Complaint: Requests annual flu shot. Denies complaints or concerns. PAIN:0 = Denies pain EXPLAINATION OF PAIN: N/A ALLERGIES: CIPRO, AMITRIPTYLINE, PENBUTOLOL, IBUPROFEN, NAPROXEN CONTACT SHEET COMPLETED BY PATIENT: Yes Depression Screen : Date: Jul 23, 2012 Results: NORMAL/NEGATIVE Alcohol Screen : Date: Jul 23, 2012 Results: NORMAL/NEGATIVE LAST ETOH USE: USED PREVIOUSLY BUT QUIT Intimate Partner Screen : Date: Jul 23, 2012 Results: NORMAL/NEGATIVE Tobacco Screen : Last TOBACCO (SMOKELESS - CHEWING/DIP) HF: NEVER USED SMOKELESS TOBACCO - Jul 23, 2012 Last TOBACCO (EXPOSURE) HF: SMOKE FREE HOME - Jul 23, 2012 Last TOBACCO (SMOKING) HF: CEREMONIAL USE ONLY - Jul 23, 2012 --------------------------------------------------------------------------- OBJECTIVE --------------------------------------------------------------------------- 42 yo FEMALE. COOPERATIVE WITH CARES:Yes PERSONAL HYGIENE: Kempt-clean grooming/clothing noted FAMILY PRESENT DURING HOME VISIT: Yes Independent HEALTH ASSESSMENT BLOOD PRESSURE: 120/58 (Jul 23, 2012@16:12) HEIGHT: 65.00 (165.10 cm) (Jul 23, 2012@16:12) PULSE: 72 (Jul 23, 2012@16:12) RESPIRATIONS: 16 (Jul 23, 2012@16:12) TEMPERATURE: 98.7 (37.056 C) (Jul 23, 2012@16:12) WEIGHT: 146.00 (66.28 kg) (Jul 23, 2012@16:12) Appetite Good Mucous Membranes : moist Skin : warm, dry, intact Lungs : clear to auscultation bilaterally Heart : Regular Rate and Rhythm Peripheral pulses : Positive x 4 extremities Edema :none noted x 4 extremities HOME ASSESSMENT HOME ENVIRONMENT: Safe without risk factors RISK FACTORS : None MODERN CONVENIENCES IN HOME (check all that apply): Electricity, Plumbing, Heating, Home Phone, Airconditioning, Stove, Refrigerator, Microwave, Cell phone --------------------------------------------------------------------------- ASSESSMENT --------------------------------------------------------------------------- KNOWLEDGE DEFICIT R/T COMMUNICABLE DX PREVENTION STORT TERM GOAL - COMPLIANCE W/ TREATMENT & FOLLOW-UP. LONG TERM GOAL - MAINTAIN OPTIMAL LEVEL OF HEALTH 1 COMM DX-P: 4 min.; INDIVIDUAL; Understanding-GOOD Comment: 2 MED - I: 4 min.; INDIVIDUAL; Understanding-GOOD Comment: 3 COMM DX-FU: 4 min.; INDIVIDUAL; Understanding-GOOD Comment: --------------------------------------------------------------------------- INTERVENTION --------------------------------------------------------------------------- MEDICATIONS RECEIVED TODAY:ZITHROMAX 1 GRAM PO REFER TO PCC 23-Jul-2012 FOR ORDERS. CONDOMS DISPENSED: Yes URINE SPECIMEN OBTAINED FOR SCREEN:Yes --------------------------------------------------------------------------- Indian Health Service Page 5-17
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