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Documentation and Coding Guidelines for Public Health Nurses 4.15 Radiology Ordinarily, public health nurses do not order imaging; but, if there is a standing order, a public health nurse must enter an imaging order in the EHR. Before doing so, a secondary provider must be entered in the patient and visit setup described in Section 4.3 above. Imaging requests are made in the Orders window. Click on the Imaging link in the left under the Write Orders heading. Figure 4.15a. Ordering an X-Ray In the Imaging dialog, select General Radiology for an x-ray. The dialog box for ordering an imaging procedure will open. Select the procedure, date for the procedure, Indian Health Service Page 4-42
Documentation and Coding Guidelines for Public Health Nurses urgency, transport, and category (outpatient in this case). The History and Reason field can hold multiple lines of text; therefore, enter as much information here as necessary. If the patient is female and in child-bearing years, the user must choose one of the options in the Pregnant field. When finished, click the Accept Order button. The new, unsigned imaging order will appear in the Orders window. Figure 4.15b. Unsigned X-Ray Order Indian Health Service Page 4-43
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DOCUMENTATION AND CODING GUIDELINES
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