Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
Neglected or Abused Individuals
Injury Prevention
The nurse needs to assess the patient’s home or community environment and
administer patient education about poisoning, falls, suffocation, drowning,
burns, etc.
Acute Illness or Crisis of an Individual Living in a Vulnerable Family
• Multiple-problem, crisis-prone family
• Socioeconomically stressed family with inadequate resources
• Dysfunctional families in need of referral, teaching, monitoring, or case
management
• Single-parent families without a support system
Terminally Ill Clients at End Stage
PHN services and coordination of care with other agencies is needed.
8.2 Priority Two
Initial Contact
The patient arrives within 1–2 weeks after the receipt of a referral or a case find.
Intensity of Visits
The patient visits every 3–8 weeks until the patient changes to another level of care
or meets the criteria for discharge.
Active Communicable Disease Under Treatment
The patient receives education on how to arrest or prevent transmission to
others in the household or the community.
Newly Diagnosed Chronic or Terminal Disease
The patient is without adequate family support and needs PHN intervention
or education.
Prenatal, Postpartum, or Newborn Without Complication
The patient needs PHN intervention and patient education
Indian Health Service Page 8-3