Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
5.7 Other PHN Visits
If care is provided in the PHN scope of practice and the nurse is not implementing a
standing order or responding to a provider referral, then documentation does not require
authentication by a medical provider. It is the discretion of the PHN to include
the primary care provider (or other clinician) as an additional signer as a means of
communicating updates on ongoing care or relevant changes that need to be brought
to the attention of the health care team. This may include communicating abnormal
findings, history, screening outcomes, identified risk factors, or significant improvements
in the patient’s status.
5.8 Resources
CMS, Updated Guidance on Medication Administration, Hospital Appendix A of the
State Operations Manual. November 18, 2011. Visit
http://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-
Items/CMS1254234.html.
Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital
Conditions of Participation. May 16, 2012. Final Rule. 77 Fed. Reg. 29033. Visit
https://federalregister.gov/a/2012-11548.
CMS, “Chapter 15: Covered Medical and Other Health Services,” Medicare Benefit
Policy Manual. Visit http://www.cms.gov/manuals/Downloads/bp102c15.pdf; go to
Section 50.3, Incident-To Requirements., and Section 80.6, Requirements for Ordering
and Following Orders for Diagnostic Tests.
Indian Health Service Page 5-26