Public Health Nursing Documentation Guidelines - Indian Health ...

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5.8 Resources ..................................................................................................................... 5-26 6.0 Using the Public Health Nursing PCC Encounter Record ............................................ 6-1 6.1 Date and Time ............................................................................................................... 6-1 6.2 Location of Encounter .................................................................................................... 6-1 6.3 Activity and Travel Time ............................................................................................... 6-2 6.4 Clinic .............................................................................................................................. 6-2 Most Common Clinic Codes for Public Health Nurses ..................................................... 6-2 6.5 Provider Codes ............................................................................................................... 6-4 Affiliation .......................................................................................................................... 6-4 Discipline .......................................................................................................................... 6-5 6.6 Measurements ............................................................................................................... 6-5 6.7 Purpose of Visit .............................................................................................................. 6-5 6.8 Medications/Interventions ............................................................................................. 6-7 6.9 Patient Education .......................................................................................................... 6-7 6.10 Immunizations ............................................................................................................. 6-8 7.0 Common Purpose-of-Visit Codes Used by Public Health Nurses .................................. 7-1 7.1 Prenatal (First, Second, or Third Trimester) .............................................................. 7-1 7.2 Postpartum ................................................................................................................. 7-1 7.3 Family Planning ......................................................................................................... 7-1 7.4 Newborn ...................................................................................................................... 7-1 7.5 Chronic Illness and Care ............................................................................................ 7-1 7.6 Immunizations ............................................................................................................ 7-2 7.7 Adolescent ................................................................................................................... 7-3 7.8 Women’s Health .......................................................................................................... 7-3 7.9 Screenings ................................................................................................................... 7-3 7.10 Elder Care or Other .................................................................................................. 7-3 7.11 Acute ......................................................................................................................... 7-3 7.12 Follow-up .................................................................................................................. 7-4 7.13 Diabetes mellitus ...................................................................................................... 7-4 7.14 Communicable Disease ............................................................................................. 7-4 7.15 History of Hazards to Health .................................................................................... 7-5 7.16 Problems With Lifestyle ........................................................................................... 7-5 7.17 Behavioral/Family Health ........................................................................................ 7-5 7.18 Case Management .................................................................................................... 7-6 7.19 Administrative and Counseling ................................................................................ 7-6 8.0 Priority, Intensity, and Timeliness for Caseload Management ................................... 8-1 8.1 Priority One ................................................................................................................... 8-1 Initial Contact .................................................................................................................. 8-1 vi
Intensity of Visits ............................................................................................................. 8-1 8.2 Priority Two ................................................................................................................... 8-3 Initial Contact .................................................................................................................. 8-3 Intensity of Visits ............................................................................................................. 8-3 8.3 Priority Three ................................................................................................................ 8-4 Initial Visit ....................................................................................................................... 8-4 Intensity of Visits ............................................................................................................. 8-4 9.0 Levels of Intervention.................................................................................................... 9-1 9.1 Primary Prevention: Prevention of Disease................................................................... 9-1 9.2 Secondary Prevention: Prevention of Complications With Existing Disease ................ 9-1 9.3 Tertiary Prevention: Improving the Quality of Life ...................................................... 9-1 vii
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