Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses Figure 4.1b. Blank Patient Chart The Patient Chart tab in the top row of tabs is active. See Figure 4.1c. The Privacy tab should be used when maintaining confidentiality without signing out of EHR, and the Resource tab provides a shortcut to RPMS. In Figure 4.1c, the patient and visit information in the blue and yellow areas have not yet been selected. Figure 4.1c. Blank Patient Chart, Patient and Visit Sections Indian Health Service Page 4-2
Documentation and Coding Guidelines for Public Health Nurses The EHR pictured in Figures 4.1b and 4.1c above is a default configuration, and the EHR you use in your local facility may appear differently. The tabs and the frames within the tab windows can be manipulated by the local clinical applications coordinator. Local EHR designs are changed to meet different providers’ documentation processes. PHN programs should discuss design options with their local clinical applications coordinators. Figure 4.1d is an example of common tabs used for comprehensive PHN documentation. Most PHN documentation in this layout would take place between the Notifications tab on the left and the Notes tab in the middle right. The tabs used less often are on the right. This layout eliminates the need to jump over one or more tabs when completing documentation. Figure 4.1d. Design Template for EHR Tab Layout 4.2 Notifications The public health nurse should check notifications at the beginning of the workday to process new consults and to review potential documentation errors. The Notifications window contains unsigned orders, notes, etc. Figure 4.2a shows a Notifications window with two items needing signature and explains how to make the patient column visible. Indian Health Service Page 4-3
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