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Public Health Nursing Documentation Guidelines - Indian Health ...

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<strong>Documentation</strong> and Coding <strong>Guidelines</strong> for <strong>Public</strong> <strong>Health</strong> Nurses<br />

PLAN<br />

---------------------------------------------------------------------------<br />

PHN Home Visit PRN<br />

---------------------------------------------------------------------------<br />

PHN Level of intervention: Primary Prevention<br />

/es/ Jane Smith, RN<br />

Registered Nurse<br />

Signed: 04/26/2011 08:52<br />

Receipt Acknowledged By:<br />

4/26/2011 12:22 /es/ Susan Pierce-Richards, ARNP<br />

Nurse Practitioner<br />

Authentication of an Implemented Standing Order<br />

Standing orders must be “authenticated by the practitioner responsible for the care<br />

of the patient,” per CMS. This can be a physician, nurse practitioner, midwife, or<br />

physician assistant. How sites choose to authenticate may vary, but the recommended<br />

process is to ensure the necessary documentation is in the nurse’s note and requests<br />

an additional signature by the ordering provider.<br />

<strong>Indian</strong> <strong>Health</strong> Service Page 5-18

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