Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses cond copy and enters information into the RPMS (which is then used to generate reports). Some PCC forms are layered, with duplicate or triplicate sheets under the top sheet. The user has to bear down when writing on the top sheet to make sure his or her handwriting is visible on the bottom layer. The nurse completing this kind of form must remember that the data entry staff will not receive the top sheet (which goes into the patient’s health record). The data entry staff will see the middle or second copy of the top sheet, posing the possibility of omission or illegibility. For example, if a hand stamp is used on the top layer of the form, the impression from the stamp is not visible on the second or third layer. Consequently, the data entry personnel will not enter that information into the database. Note: the PCC form (and any copy of it) is subject to requirements of the Health Insurance Portability and Accountability Act. Public health nurses should familiarize themselves with these requirements. And, the PCC form must adhere to accreditation standards for physical security of patient information. Nurses should understand how their data entry staff gleans information from PCC forms. Data entry staffers are trained to read PCC forms in a certain sequence. Until recently, they scanned across the top of the form from the left to the right. Then, they moved down the right side of the form until they got to the purpose of visit and a valid signature. After that, they went to the next form. Now, there are more pieces of information they need to collect to meet accreditation standards and Government Performance and Results Act requirements. Bottom line: information entered into the RPMS must be accurate, complete, and timely. By knowing where and what to document in legible handwriting, nurses can contribute to a smoother data generation process and, in turn, improve patient care, data quality, and, where appropriate, revenue. Page 1-11
Documentation and Coding Guidelines for Public Health Nurses 2.0 DO’S AND DON’TS OF PUBLIC HEALTH NURSING DOCUMENTATION 2.1 Do’s • Document that you have the correct chart number or have retrieved the correct patient in the Electronic Health Record (EHR) before you begin documentation. • Make sure your documentation reflects the nursing process and your professional capabilities. This includes all EHR components as well as a note for every visit. • Document legibly. Check spelling before signing a note in EHR. • Document the time you gave a medication, the administration route, and the patient’s response. Document the Five Rights, which are the: o right patient, o right medication, o right dose, o right route, and o right time. • Document precautions or preventive measures used. • Document each phone call and text message to a physician or patient, including the exact time, message, and response. • Document patient care at the time you provide it or as soon as possible. Be sure documentation is completed at the end of each workday. • Document the reasons for care and service refusals. • Document why the patient, parent, or guardian refused care or service. Also document the education and intervention provided that outlined the potential risks and complications of refusal. Include the patient education codes. Good documentation protects the nurse from risks associated with adverse patient outcomes when care or services are refused. Indian Health Service Page 2-1
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