Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses 4.5 Allergies Public health nurses are allowed to add allergies in the EHR. To enter a patient’s allergies or to edit an existing one, go to the Adverse Reactions area (Figure 4.5a), which is located in the Review tab if you’re using the default EHR design. Figure 4.5a. Adverse Reactions Right click anywhere on the Adverse Reactions area and a pop-up menu will appear. Select New Adverse Reaction (or Edit Adverse Reaction for an existing one). Figure 4.5b. Lookup Causative Agent Dialog Box In the Look up Causative Agent dialog box (Figure 4.5b), enter an allergy cause at the top and click the Search button. Select an item from the list that appears below the causative agent you entered. Then, click the OK button. Indian Health Service Page 4-10
Documentation and Coding Guidelines for Public Health Nurses The Create Adverse Reaction dialog box will appear (Figure 4.5c). Be sure to select a sign or symptom on the lower left and, using the green arrow, move it to the Selected area on the lower right. When finished, click the OK button. Figure 4.5c. Create Adverse Reaction Dialog Box The new allergy will appear in in the Adverse Reactions area. See Figure 4.5d. Figure 4.5d. New Adverse Reaction Indian Health Service Page 4-11
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DOCUMENTATION AND CODING GUIDELINES
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FOREWORD This manual was written by
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