Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses 4.13 Medications Ordinarily, public health nurses do not order medications. However, if there is a standing order, a public health nurse must enter a medication order in the EHR. Please refer to Section 5.0 of this manual for the standing orders documentation process. Public health nurses may encounter patients that receive medications from outside sources, such as Veterans Affairs or private clinics. EHR patch 10 has an option to enter outside medications into the system, allowing primary care providers the ability to review medications the patient takes that are not ordered or filled by the inhouse pharmacy. This process provides reconciliation of all patient medications. Go to the Medications tab and select “non” facility medications. Then, click New and a dialog box will appear. See Figure 4.13a. Figures 4.13a–e show how to document an unknown outside medication. Figure 4.13a. Outside Medications, Step One Indian Health Service Page 4-34
Documentation and Coding Guidelines for Public Health Nurses Figure 4.13b. Outside Medications, Step Two Indian Health Service Page 4-35
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DOCUMENTATION AND CODING GUIDELINES
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