Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses • If you remember an important point after you’ve completed your documentation, chart the information with a notation that it is a late entry. Include the date and time of the late entry. • Document often enough to tell the whole story. 2.2 Don’ts • Don’t document a symptom, such as “c/o pain,” without also charting what you did about it. • Don’t alter a patient’s record; this is a criminal offense. • Don’t use shorthand or abbreviations that aren’t widely accepted. See the approved abbreviations list at your facility. They may differ from facility to facility. • Don’t document imprecise descriptions, such as “bed soaked” or “a large amount.” • Don’t document what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately. • Don’t document care ahead of time. Something may happen to prevent you from actually giving the care you’ve charted. Charting care that you haven’t done is considered fraud. Indian Health Service Page 2-2
Documentation and Coding Guidelines for Public Health Nurses 3.0 SETTING UP PUBLIC HEALTH NURSING CLINICS IN THE RESOURCE AND PATIENT MANAGEMENT SYSTEM The public health nurse must communicate to the site manager, clinical application coordinator, or health information manager the list of clinic codes (Tables 1.1.1 and 3.5) that describes their visits. This step is required before entering patient documentation. 3.1 Log onto the RPMS To open the RPMS software, double click the RPMS icon. RPMS will prompt the user for an access code. Note: The RPMS software requires the use of all capital letters. Type in your access code. The software will display asterisks in place of what you type. Hit return or the Enter key. Type in your verify code, and type Enter again. You are now logged in. You will stay logged into RPMS until you quit the program or until one of these two instances happens: 1. you do nothing for 15 minutes, or 2. you mistype the access code or verify code during three successive attempts to login. In the first instance, when the system automatically logs you out after a period of inactivity, simply type Enter and repeat the login process. After you log back in, the system will ask you if you want to return your previous location. In the latter instance, you will have to shut down the program and restart the computer. After restarting, double click the RPMS icon and try to login again. Contact the information technology specialist if the problem persists. Indian Health Service Page 3-1
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