Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses As public health nurses think about documentation using the nursing process as a guide, they must consider the subjective-objective-assessment-plan format (SOAP) outlined in Indian Health Service policy quoted below. Indian Health Manual Part 3: Professional Services Chapter 3: Health Information Management … 3–3.2 Health Record … D. Electronic Health Records. Electronic capture and storage of patient health information will be implemented to enhance access to patient data by health care practitioners and other authorized users. Electronically stored and/or printed health information is subject to the same medical and legal requirements as handwritten information in the health record. … 3–3.8 Health Record Documentation … AQ. Progress Notes. IHS adopted the Problem-Oriented Record System; therefore, notes should be written in the subjective, objective, assessment, and plan (SOAP) format. The progress notes must document the patient’s course and response to treatment. The frequency of the physician’s or other licensed independent practitioner’s progress notes is determined by the change in the patient’s condition, but must be adequate to document the severity of illness and the intensity of service during the patient’s hospitalization. … Chapter 4: Nursing … 3–4.5 Nursing Practice Management Page 1-5
Documentation and Coding Guidelines for Public Health Nurses … E. Nursing Process. The nursing process (assessment, diagnosis, planning, intervention, evaluation), the framework of nursing practice, shall be applied and documented in all three areas of nursing practice: inpatient, ambulatory and public health nursing. Figure 1.1 Public Health Nursing Process PHN Assessment PHN Evaluation PHN Diagnosis PHN Interventions PHN Outcome PHN Planning Nursing assessment includes subjective and objective information. Subjective data is data that the patient states significant to his or her current condition, according to Patricia A. Duclos-Miller, author of Managing Documentation Risk: A Guide for Nurse Managers. Duclos-Miller writes, “[I]f the patient says something that can be used to demonstrate mental, behavioral, or cognitive status at the time of the assessment, [then] documentation of the conversation can be used to measure progress or decline over the course of treatment.” Objective data includes data that can be measured, such as vital signs and results of tests. Duclos-Miller writes, “The physical exam of the patients—which includes key Page 1-6
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