Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
4.7 Chief Complaint
Public health nurses must add a chief complaint for a patient encounter. Clicking
the “CC/PROBS” tab (in the default EHR design) reveals the Chief Complaint and
Problem List page. Figure 4.7a shows an example of what this page looks like before
a chief complaint has been entered. Click on the Add button on the far right in the
Chief Complaint area. The Chief Complaint dialog box will appear. Type in the patient’s
chief complaint in the text box in the top half, as shown in Figure 4.7b. Below
the text box is a list of symptoms to choose from. Because most of the symptoms refer
to ambulatory patients visiting a health center, a public health nurse will probably
not use this option. Click the OK button to close the Chief Complaint dialog box.
The new chief complaint appears in the Chief Complaint area of the CC/PROBS
window.
Information for the Problem List and the Triage Summary (in the middle of the
window) is entered in other parts of the EHR.
Figure 4.7a. Chief Complaint and Problem List Window; Add Button Circled
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