Public Health Nursing Documentation Guidelines - Indian Health ...

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