Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses If a patient has “No Allergy Assessment” and has no allergies, then it is extremely important that an entry of “No Known Allergies” is entered into the Adverse Reaction frame. To enter “No Known Allergies,” right click anywhere on the Adverse Reactions area and a pop-up menu will appear. Select New Adverse Reaction and the Look up Causative Agent window will appear. Select No Known Allergies at the bottom and “click” OK. Figure 4.5e. No Allergy Assessment Complete to Date Figure 4.5f. No Known Allergies Indian Health Service Page 4-12
Documentation and Coding Guidelines for Public Health Nurses When the patient without allergies returns at a later date, you’ll need to verify in EHR that he or she still has no allergies. Right click in the Adverse area to bring up a pop-up menu, and select Chart Review. In the side menu that pops up, select No Known Allergies. See Figure 4.5g. Indian Health Service Page 4-13
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DOCUMENTATION AND CODING GUIDELINES
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Public Health Nursing Documentation Guidelines - Indian Health ...

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