Public Health Nursing Documentation Guidelines - Indian Health ...

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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
Documentation and Coding Guidelines for Public Health Nurses the facility-required format (usually, SOAP or SOAPIE format) and include the following items. Referred By The template should include the ordering provider’s name or medical service (obstetric ward for example), as well as the date when the referral or consult was received. Chief Complaint An example of a chief complaint would by a PHN home visit for blood pressure check, assessment, and teaching home management for the monitoring of end-stage renal disease per provider consult order. The chief complaint should also include the subjective assessment. Other Items Nursing diagnosis, outcome identification, planning, and initiation of interventions should be clearly documented in the nurse’s note, including what orders were implemented and the evaluation of interventions. Authentication of Referred Care Authenticate the service provided by adding the referring provider as an additional signer on the PHN consult note after signing. (Refer to the end of Section 5.4 above for the authentication process.) This completes the PHN referral process and authenticates the services provided. Exception: Influenza and Pneumovax do not require authentication by the provider for Medicare. However, your facility or state Medicaid agency may require additional documentation. Please check with your PHN department. Indian Health Service Page 5-25
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