Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
The Diagnosis Lookup dialog box will
open in front of the Add POV dialog
box. With the Lookup Option set to
“Lexicon” (text), type key words in the
Search Value field and click the
Search button. A list will appear below
the Search Value field. Choose the
most appropriate code in the list and
click the OK button to save and close
the Diagnosis Lookup box. In the Add
POV box, select Primary Diagnosis.
Add a narrative and any necessary
other information and click the Save
button. The new purpose of visit will
be visible in the Visit Diagnosis area
of the POV window.
Figure 4.10c. Visit Diagnosis Area
After POV Added
An easier way to add a visit diagnosis (POV) is to use the ICD–9 Pick List. Figure
4.10d shows the ICD–9 Pick List area with a diagnosis chosen. To view pick lists, activate
the Show All option in the lower left. The pick lists that appear will depend on
the facility where the EHR is located. In Figure 4.10d, the “Phn” list is selected. This
is a local version of a public health nursing list. The items on this list are displayed on
the right. Each item has a check box. More than one item can be selected. In Figure
4.10d, V79.0–Screening for Depression is chosen. As a result of this selection, depression
screening now appears in the Visit Diagnosis area. See Figure 4.10e.
Figure 4.10d. ICD–9 Pick List With Pick List Selected and Diagnosis Chosen
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