Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses 4.16 Reports Public health nurses can generate and view a number of reports from the patient chart in the Reports window. Simply select one of the report titles on the left under the Available Reports heading. The EHR will generate a report with the latest information entered in the main area of the Reports window. The Daily Order Summary is displayed in Figure 4.16. Figure 4.16. Reports Window; Daily Order Summary Selected EHR report options are similar to health summary and predefined reports in RPMS. To capture statisitical data and PHN program management, one still needs to access RPMS directly for enhanced reports, such as VGEN and others. Indian Health Service Page 4-44
Documentation and Coding Guidelines for Public Health Nurses 4.17 Consults To view a patient’s consults, click on the More tab (if you’re using the default EHR design) first to reveal a second row of tabs, then click on the Consults tab. Figure 4.17a. Clicking the More Tab to Reveal the Consults Tab A list of consults (typically sorted by date) will appear on the left under the All Consults heading. Choosing one of the consults in this list will reveal the entire consult text in the main area of the Consults window (Figure 4.17a). The ability of public health nurses to order consults in the EHR varies by facility. If a user has the need and ability to order a consult, there are two places to start a consult. One is at the New Consult button in the Consults window. The other is at the Consults link in the Orders window. See Figure 4.17b. Either option will open the consult ordering dialog box (Figure 4.17c). In the dialog box, select a service or specialty. Enter a reason for consult in the Reason for Request text field. Click the Accept Order button when finished. Indian Health Service Page 4-45
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DOCUMENTATION AND CODING GUIDELINES
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