Public Health Nursing Documentation Guidelines - Indian Health ...

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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
Documentation and Coding Guidelines for Public Health Nurses by choosing his or her name in the Providers for This Encounter area and clicking on the red “P.” In Figure 4.3c, USER,ISTUDENT is the public health nurse, and USER,XSTUDENT is the physician. Clicking on the Appointments/Visits tab reveals visits already created by public health nurse USER,ISTUDENT. If the public health nurse will be entering any orders, he or she must set an ORES key holder (physician, nurse practitioner, physician assistant, etc.) as the visit context provider. To do this, highlight the individual—it will be blue—and click OK. You will notice that the selected individual is the provider in the Visit box. That individual will be the “ordered by” provider on orders. The logged in user is the “entered by” on all entries. Click the OK button when finished. The user will be returned to the patient chart. The Visit Location will appear in the yellow area along with the date and time of the visit. Indian Health Service Page 4-7
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DOCUMENTATION AND CODING GUIDELINES
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