Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses 4.14 Labs A patient’s laboratory test results are viewable in the Labs window. Selecting an option in the Lab Results area on the left allows the user to view all or some lab results or to view certain kinds of lab results. See Figure 4.14a. Figure 4.14a. Labs Window Ordinarily, public health nurses do not order laboratory tests. However, if there is a standing order, a public health nurse must enter a lab order in the EHR. Tests performed at the point of care and tests waived by the Clinical Laboratory Improvement Amendments (http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/) must be documented by public health nurses. The point of care in the laboratory package uses the Fast Bypass option to order, accession, result, and sign in one process. Use the following steps to complete a nursing order for point-of-care testing. Indian Health Service Page 4-38
Documentation and Coding Guidelines for Public Health Nurses 1. With a patient and visit selected, click the POC Lab Entry button to open the Point of Care Data Entry Form dialog box. Figure 4.14b POC Lab Entry Button 2. Select the test to be performed from the list. Figure 4.14c Lab Point of Care Data Entry Form Dialog Box 3. Enter the test information and test results. 4. Select the nature of the lab order or change. If the test was done by policy, the nurse must select “Policy” as the nature of the order and follow the documentation guidelines. Only select “Written” if there is a prior written order in the medical chart or record for that patient for the point-of-care test. Indian Health Service Page 4-39
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DOCUMENTATION AND CODING GUIDELINES
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Public Health Nursing Documentation Guidelines - Indian Health ...

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