Public Health Nursing Documentation Guidelines - Indian Health ...

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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
Documentation and Coding Guidelines for Public Health Nurses Figure 4.6d. Select New Date and Time Dialog Box After clicking the Historical Visit button, the Select Location for Historical Entry dialog box (Figure 4.6e) opens. In the Select location area, choose the Other or Facility radio button. If you choose Other, type in the facility name in the text field. If you choose Facility, scroll or search for the facility name in the Select Facility area. Click OK when finished. Figure 4.6e. Select Location for Historical Entry Dialog Box Indian Health Service Page 4-17
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DOCUMENTATION AND CODING GUIDELINES
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FOREWORD This manual was written by
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Documentation and Coding Guidelines
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Public Health Nursing Documentation Guidelines - Indian Health ...

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