Public Health Nursing Documentation Guidelines - Indian Health ...

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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
Documentation and Coding Guidelines for Public Health Nurses 6.0 USING THE PUBLIC HEALTH NURSING PCC ENCOUNTER RECORD Use the following guidelines to complete the Patient Care Component (PCC) form for public health nursing (PHN). Special care must be taken when completing the PCC form, especially with regards to handwriting. Please read Section 1.2, Understanding the Data Collection Process. 6.1 Date and Time Write the date and time in the upper left corner of the form as shown in Figure 6.1. Figure 6.1. Date and Time • Date is a mandatory field. The Resource and Patient Management System (RPMS) will not allow the data entry staff to begin a record without this information. • If a specific time is not included on this line, the RPMS will set the visit time to 12 noon. • Including a specific time becomes even more important if two visits to the same patient take place on the same day. RPMS will not accept records for two visits to the same patient at the same time. 6.2 Location of Encounter This is also a mandatory field. Terms such as “home,” “jail,” “school,” “office,” “grocery store parking lot,” or “nursing home” are acceptable. Figure 6.2. Date, Time, and Location Indian Health Service Page 6-1
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