Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
4.8 Patient Education, Health Factors, and Exams
The public health nurse must document the patient education delivered, the patient’s
health factors (such as smoking), and exams administered. These items can
be found in the Wellness window (Figure 4.8).
Figure 4.8. Wellness Window
There are some things to pay attention to.
Health Factors
The Health Factors area is where much documentation required by Government
Performance and Results Act occurs, including:
• alcohol use (CAGE assessment only);
• tobacco use and exposure (smoking, smokeless, chew, and dip); and
• barriers to learning physical activity, etc.
Personal Health
The Personal Health area is key for patient-specific information.
Indian Health Service Page 4-22