Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses 5.5 Immunization Standing Order Initiation should be documented in the Immunization Record in EHR (Section 4.9 above) and in a note (Section 4.12). CMS considers immunization standing order initiation the same as a medication standing order, with the exception of influenza and Pneumovax, which do not require a medical provider authentication. (This only applies to adults. If your state doesn’t have a law or position summary supporting this, nurses may be violating their state practice act.) Other non-patient-specific orders for immunizations and communicable disease outbreaks—pertussis outbreak, tuberculosis, sexually transmitted infections, hepatitis, measles, hanta virus, etc.—must be covered by medical staff-approved policies or procedures. If your site has deployed the clinical reminders package, using a reminder dialog box will document a note and enter immunization component data into RPMS and EHR at the same time. Ask your clinical applications coordinator about using reminder dialog boxes. Public health nurses must verify they have current standing orders for immunizations. They must also ensure they have the legal scope of practice and the PHN department policy to interpret and initiate standing orders. Standing orders need to be reviewed and updated annually. If inspectors find old standing orders or orders lacking signatures, you will be cited. Nurses must document the required assessment and the administration of vaccines using approved formats (SOAP, SOAPIE, or reminder dialog tool) based on IHS Area and local policies. Immunization Documentation Example #1 The nurse documents the chief complaint and the vital signs of a child who presents with mother for an immunization update, as shown in the Chief Complaint dialog box below. Indian Health Service Page 5-20
Documentation and Coding Guidelines for Public Health Nurses The nurse documents the vaccine given in the Immunization Record (Section 4.9 above). The nurse records the vaccine, lot, injection site, etc. The V Chief Complaint, V Measurements, and V Immunizations objects to automatically fill in the nurse’s note, as shown below. Resulting Note The following note is the result of Immunization Documentation Example #1. The note is authenticated using the Identify Additional Signer function. S: Chief Complaint: Patient presents with mother for immunization update. Screened and no contraindication for today's immunizations which are given by per standing order. O: TMP:98.20 (36.7 C), PU:80, RS:16, BP:100/60, WT:88.18 (40.04 kg) A: Immunization Update P: The following immunizations were given per standing order. HEP B,ADULT /es/ Jane Smith, RN Registered Nurse Signed: 04/26/2011 08:52 Receipt Acknowledged By: 4/26/2011 12:22 /es/ Susan Pierce-Richards, ARNP Nurse Practitioner Indian Health Service Page 5-21
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