Public Health Nursing Documentation Guidelines - Indian Health ...
Public Health Nursing Documentation Guidelines - Indian Health ...
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 />
Resulting Note<br />
The following note is the result of Immunization <strong>Documentation</strong> Example #2. The<br />
note is authenticated using the Identify Additional Signer function.<br />
S:<br />
Chief Complaint: Patient presents with mother for immunization update.<br />
Screened and no contraindication for today's immunizations which are given by per standing<br />
order.<br />
O: TMP:98.20 (36.7 C), PU:80, RS:16, BP:100/60, WT:88.18 (40.04 kg)<br />
A: Immunization Update<br />
P: ***** CLINICAL REMINDERS ACTIVITY *****<br />
Td/Tdap:<br />
Tdap Immunization information.<br />
Patient received Tdap immunization at this visit<br />
per standing order<br />
Lot Number: AC2B054BA<br />
Imm Site: Left deltoid im<br />
Injection Volume: 0.5<br />
Vacc Info Sheet Date: November 18, 2008<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 Immunization Standing Order<br />
Immunization standing orders must be authenticated, with the exception of influenza<br />
and Pneumovax. See the Authentication of an Implemented Standing Order subsection<br />
above under Section 5.4.<br />
<strong>Indian</strong> <strong>Health</strong> Service Page 5-23
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