Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
entry, or patient business office. The Centers for Disease Control and Prevention has
an entire Web site dedicated to the International Classification of Diseases at
http://www.cdc.gov/nchs/icd.htm.
Nurses are sometimes reluctant to put a medical diagnosis on the PCC. However, if
a medical diagnosis—for instance, diabetes—has already been made by a physician,
then the nurse is not making his or her own diagnosis if he or she writes “diabetes
foot care” or “diabetes—knowledge deficit related to insulin administration.” In addition,
because the purpose of visit represents the highest level of knowledge, it is appropriate
for the nurse to document his or her level of knowledge (e.g., “papular, diffuse,
rash”) without having to make a diagnosis of specific cause.
Although primary data entry and retrieval is based on medical diagnosis, nursing
diagnosis is still very appropriate and is encouraged for use in the purpose of visit
section. The nursing diagnosis must include the phrase “related to” followed by the
medical diagnosis. If the diagnosis is not definitely established—tuberculosis suspect,
unconfirmed pregnancy, or possible strep throat—then the nurse should document
symptoms rather than a diagnosis. For example, if unsure of the diagnosis,
write “sore throat” instead of “possible strep throat.” The rule is to document the
highest level of knowledge. So, if the client has abdominal pain and the cause is unknown,
then write “abdominal pain,” not “possible gallbladder disease” or “rule out
appendicitis.” The terms “rule out,” “possible,” “probable,” etc., should not be used in
the purpose of visit field.
The diagnosis, assessments, and problems documented in this section are printed
verbatim in the Outpatient and Field Encounters section of the patient’s Health
Summary.
Indian Health Service Page 6-6