Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
4.3 Set Up Patient and Visit
The first order of business is to select a patient. Click on the blue area. The Patient
Selection dialog box will appear. See Figure 4.3a. Either type in a patient’s name
(last name first) or choose the patient’s name in the scroll box. The HRN number is
the patient’s chart number. Click the OK button when finished. The patient information
will now appear in the blue area. See Figure 4.3b.
Next, click on the yellow Figure 4.3a. Patient Selection Dialog Box
visit area. The Encounter
Settings for Current Activities
dialog box will
pop up. Click on the New
Visits tab. The public
health nursing visits set
up in RPMS—see Section
3—should appear in Visit
Location scroll box.
Choose a visit. Select a
date and time. Click the
Create a Visit Now check
box. When this box is
checked, a new area will appear called Providers for This Encounter. The public
health nurse will need to select his or her name in the All Providers scroll box and
move it to the
Figure 4.3b. Patient Chart With Patient Info; Visit Blank
Providers for This
Encounter area by
clicking on the
green arrow. The
nurse can also select
another provider—e.g.,
a primary
physician—
and move his or
her name into the
Providers for This
Encounter area.
The nurse can designate
herself or
himself as the
primary provider
Indian Health Service Page 4-6