Public Health Nursing Documentation Guidelines - Indian Health ...

Documentation and Coding Guidelines for Public Health Nurses
Clinic Name (RPMS)
and Visit Location
(EHR)
Definition
Clinic
Code
and
Location
Code
Service Category
(RPMS) and Type of
Visit (EHR)
PHN Visit to Inpatient
PHN Home Visit
PHN Home Not Found
PHN Immunization
PHN School
The nurse had an encounter with a patient
while the patient was located in inpatient
ward. Examples include a lactation consultation
for new mother or referral from a
provider.
The nurse provided health care service to
a patient in the patient’s home.
The nurse attempted to provide health
care service at the patient’s home, but the
patient was not home.
An organized clinic (such as a flu clinic)
provided assessment and administration of
immunizations.
An organized clinic at a school provided
nursing, education, or counseling services
to school-age children (kindergarten
through 12th grade). Do not use this code
for an immunization clinic at a school; see
above.
45 Inpatient
11 Ambulatory
11 Not Found
12 Ambulatory
22 Ambulatory
PHN Homeless
The nurse provided services to a patient
living in a homeless shelter, in transitional
housing, on the streets, or with friends or
relatives.
D3
Ambulatory
PHN Homeless Not
Found
The nurse attempted to provide service to
a homeless patient (defined above), but
the patient was not found.
D3
Not Found
PHN Telephone
PHN Phone Not Found
PHN Chart Review
The nurse contacted an individual via telephone
for a significant, health-related
intervention. This includes contact by text
messaging.
The nurse unsuccessfully attempted to
contact an individual via telephone or text
message for a significant, health-related
intervention.
The nurse’s review of the medical record
resulted in the documentation of medically
significant information. This code does
not include a patient visit.
51 Telecommunication
51 Not Found
52 Chart Review
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