Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
The third column, “LOU,” is where the patient’s level of understanding is recorded.
This space must contain one of the following codes: G for good, F for fair, P for poor,
R for refuses education, and GP for group education. It is imperative to document
refusal of any education in this area.
The fourth column, “TIME,” is notated in minutes (with no fractions) in the same
fashion as the activity and travel times at the top left of the PCC form. Each patient
education topic used must have an individual time assigned to it.
Nurses are required to initial each topic taught in the right margin (not shown in
Figure 6.9). Data entry staff persons will not enter patient education information
into the RPMS if it is not initialized. Initializing the topics also informs the data entry
staff regarding who exactly provided the patient education.
6.10 Immunizations
The nurse must document any immunizations given on the far right of the PCC form
under the patient education section. The most commonly administered vaccines are
listed in the “IMMUN” column, but there are a few empty spaces at the bottom of
the column to write in vaccines not listed. The nurse needs to indicate the lot number
of the vaccine given in the “LOT #” column and leave the number sign (#) column
blank. Nurses must include their initials in the right margin of the row of each vaccine
administered. Immunizations that are not initialized are not entered into the RPMS.
A vaccine information sheet must also be completed in addition to the PCC form. Site
and route of administration should be documented in the narrative.
Many facilities have implemented point-of-service data entry, increasing the accuracy
of the immunizations entered in the RPMS. As long as the facility maintains a
paper record, it is the nurse’s responsibility to document completely the immunizations
given.
Indian Health Service Page 6-8