Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
6.8 Medications/Interventions
Several rows below the purpose of visit
section is the medications/interventions
part of the PCC form. Nurses should enter
the treatments, procedures, etc., that
are considered part of the treatment (as
opposed to being part of the assessment).
Prescriptions and one-time doses
of medications administered at the time
of the visit are recorded in this section.
The time, dose, route (including site of
injection), and the nurse’s initials or legal
signature are required for medications
administered by the nurse.
Figure 6.9. Blood Pressure and Patient Education
(Topic, Level of Understanding,
and Time)
6.9 Patient Education
Nurses must complete the patient education
section, labeled “PT. ED,” on the
far right side of the PCC form under the
blood pressure field. Codes take the
place of narratives in this section to facilitate
data entry.
The Indian Health Service has two extensive
publications that are helpful in
choosing the correct patient education
codes. Documenting Patient Education,
Volume 1 describes the processes for describing
patient education. Patient and Family Education Protocols and Codes, Volume
2 contains the entire list of outcomes and standards for all education topics.
Copies of both are available in IHS hospitals and clinics. They are also available at
http://www.ihs.gov/HealthEd/?module=pepc.
The patient education section of the PCC form is divided into four columns. The first
column has preprinted abbreviations of the patient education services most commonly
performed by public health nurses. There are a few empty boxes at the bottom of
the column to fill in other patient education services. The second column, titled
“TOPIC,” is really a subtopic of the first column. In Figure 6.9, the letter “N” is
marked in the topic column in the “Breastfeed BF” row, signifying “BF-N, Nutrition
(Maternal).”
Indian Health Service Page 6-7