Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
The Mvimmunizations pick list contains one item: 90707–MMR (measles, mumps,
and rubella vaccine). When 90707–MMR is checked in the Super-Bills area, it appears
in the Visit Services area. The dotted red line in Figure 4.11b reflects the process
described here.
Another way to add a service rendered is through the Historical Services area. Follow
the dotted green line in Figure 4.11b. In this process, a glucose blood test performed
on August 18, 2005, is selected. Once an item in the Historical Services area
is selected, all the user has to do is click the Add to Current Visit button to add the
item to the Visit Services area.
If the nurse cannot find the service rendered in the pick lists or Historical Services,
he or she must click the Add button in the Visit Services area and add a service using
the Add Procedure for Current Visit dialog box (Figure 4.11c). In the dialog box,
click on the ellipsis (…) button at the top to choose a procedure.
Figure 4.11c. Dialog Box: Add Procedure for Current Visit
Indian Health Service Page 4-29