Public Health Nursing Documentation Guidelines - Indian Health ...

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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
Documentation and Coding Guidelines for Public Health Nurses Complete a reproductive history for any female patient, and keep it up to date. If you are using a version of EHR other than patch 10, then this component remains under personal health. In EHR patch 10, reproductive history is its own component. Complete a functional assessment for elderly or at-risk clients. Complete a breastfeeding assessment on newborns through their breastfeeding duration. Note: infant feeding is found in the infant feeding section. Exams The Exams section includes screenings for intimate partner violence, depression, alcohol, foot inspection, fall risk, and newborn hearing screening. Indian Health Service Page 4-23
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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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