Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
5.6 PHN Referrals
Many PHN visits are not initiation of standing orders; rather, they represent both
delegated actions and referred care. Examples of PHN referrals are patient education,
blood pressure checks, and PHN patient assessments that were requested by
the supervising medical provider.
It is important to establish the link between the referring medical provider and the
nonphysican provider: in this case, a public health nurse. How health care facilities
choose to satisfy the documentation of the link between the public health nurse and
the referring physician for “incident to” billing may vary. “See Section 5.4 above
about “incident to” rules for Medicare billing.” A straightforward way would be for
the nurse performing the service to add the referring provider as an additional signer
who would review or sign to acknowledge the receipt and who would review of the
progress. Regardless of method chosen, it would be wise to have an established process
and policy at the facility.
Recommended Steps for Referred Care
First, the medical provider refers patients to the PHN department by entering a
consult request in EHR using a quick order. Or, the medical provider selects Option:
New from the consult drop-down menu, as shown below, and requests services to be
provided by the PHN department.
Second, the PHN department electronically receives the consult, and the public
health nurse provides the requested services.
Third, the public health nurse documents the encounter with the patient using the
appropriate consult note title.
Documentation of Referred Care
Check with your clinical applications coordinator for the consult note title appropriate
to your facility.
You will be asked to associate the consult note with the consult request.
Using a TIU template to document the PHN consult note improves the consistency
of nursing documentation. Your clinical applications coordinator can help you create
a TIU template if you do not have one already. This template should be developed in
Indian Health Service Page 5-24