Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
4.12 Notes
Public health nurses must complete a progress note for all patient visits. The body of
the progress note should contain a narrative about health factors, screenings, immunizations,
and other services performed. However, it is important also to include
this information in other relevant parts of the EHR. Otherwise, crucial data will not
be included in reports generated by the health facility, because the body of the progress
note is not included in these reports. Hence, an immunization discussed in the
progress note must also be documented in the Immunizations section of the EHR.
If your process includes medical orders (lab, consults, medications,
radiology, etc.), you must ensure that the order has been
entered before completing your nurse’s note.
Click on the Notes tab (if you’re using the default EHR design). Notice the expandable-contractible
list of templates on the left. Find a template for a public health
nursing SOAPIE (subjective-objective-assessment-plan-intervention-evaluation)
note. Select the PHN SOAPIE template and right click on it. A pop-up menu will appear.
Select Insert Template in the pop-up menu. See Figure 4.12a.
Indian Health Service Page 4-30