Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
To reduce documentation errors, it’s recommended that a public health nurse have a
conversation with the clinical applications coordinator requesting to set the default
of the vital entry component to the date and time of the current visit. This default
provides improved EHR efficiency by decreasing the number of clicks, because the
vitals entered will automatically default to the visit time and date.
Historical Measurements
Public health nurses experience situations where documentation of patient encounters
may not happen on the same day. Historical measurements can be entered
through the vital entry component and are designed to capture measurements transcribed
from outside records, such as birth weight or cardiac ejection fraction from
echocardiogram reports. This creates a historical event and should not be confused
with a late entry.
To enter historical measurements in EHR, right click in the Vitals frame and select
Enter Vitals in the pop-up menu. The Vital Measurement Entry dialog box will appear.
Click on the New Date/Time button, and the Select New Date/Time dialog box,
shown in Figure 4.6c, will appear.
Figure 4.6c. Select New Date and Time Dialog Box
The default setting is Now. You may change to the date and time of the current visit
by clicking the radio buttons labeled Current Visit and Historical Visit, which is circled
in Figure 4.6d.
Indian Health Service Page 4-16