Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
concerning where “not found” should be indicated on the public health nursing
PCC note.
12 = Immunization
This clinic code includes immunizations at schools or elsewhere.
09 = Grouped Services
This code is not as explicit as others. Better choices include code 45 for health
screenings, 53 for immunization letters, or 52 for chart reviews. More about
grouped services appears later in this section.
22 = School
Except for immunizations, this code includes all public health nursing services
performed at a school.
25 = Other
Code 25 is to be used only when there is absolutely no other code to fit a public
health nursing service.
4 5 =PHN Clinic Visit
In addition to visits held at a PHN office, this code includes visits to designated,
organized programs or screenings, such as health screenings at a
chapter house. It also includes patients seen at a “delivery of service” site,
like a casino or the parking lot of a grocery store, etc.
51 = Telephone Call
52 = Chart Review or Record Modification
53 = Follow-up Letter
Codes 51, 52, and 53 include reminder letters, follow-up to a failed appointment
for an abnormal test result (e.g., follow-up to an abnormal Pap smear or
mammogram), or delinquent immunization letters.
60 = Education Classes
Prenatal classes, diabetes education classes, etc.
77 = Case Management Services
This clinic may be used when public health nurses are case managing a client
that has a chronic or long-term prognosis. It’s also used to document collabo-
Indian Health Service Page 6-3