Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses Noncompliance With Medical Treatment—Nonemergency The patient needs PHN intervention and patient education regarding hazards to the patient’s health. Nonemergency Psychosocial Situations The patient needs PHN support to cope, seek appropriate intervention, and identify resources for unresolved grief, a dysfunctional family situation, etc. Infants, Children, and Adults With Special Needs The patient needs PHN intervention or patient education to access resources for mental or physical developmental deficits. Delinquent Immunization Status The nurse must monitor and track patients defined in the PHN caseload. Patients With a History of Recurrent Episodes of Illness or Hospitalization PHN intervention and patient education is needed. Safety Hazards PHN assistance is needed to identify safety hazards and resources for correction. Health Promotion/Disease Prevention • Individual, family, and community education • Patients with knowledge deficits needing teaching regarding disease, treatment, medication, and understanding principles needed to carry out treatment 8.3 Priority Three Initial Visit The patient arrives 1–2 weeks after the receipt of a referral or a case find. Intensity of Visits The patient visits every 3–12 months until the patient changes to another level of intensity or meets the criteria for discharge. Indian Health Service Page 8-4
Documentation and Coding Guidelines for Public Health Nurses Chronic or Debilitating Illness, Infection, or Communicable Disease Under Treatment With Family Support The patient needs occasional PHN monitoring, intervention, assessment, evaluation or education. Individuals, Families, or Groups With Health Promotion or Disease Prevention Issues not Addressed in Priority One or Two This priority includes screening for seniors, diabetes, schools, child find, etc. Individuals or Families Who Have Reached the Highest Level of Function The patient needs PHN intervention to prevent regression. Indian Health Service Page 8-5
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DOCUMENTATION AND CODING GUIDELINES
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FOREWORD This manual was written by
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4.13 Medications ..................
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Documentation and Coding Guidelines
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Public Health Nursing Documentation Guidelines - Indian Health ...

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