Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses 4.20 Refreshing Data on the Screen If the latest data entered does not appear in the patient chart, try “refreshing” the screen. In the Patient menu in the Windows menu bar at the top, select Refresh Data. Figure 4.20. Refresh Data Indian Health Service Page 4-50
Documentation and Coding Guidelines for Public Health Nurses 5.0 STANDING ORDER DOCUMENTATION Documentation of nursing care and nursing actions is a professional standard for nursing practice. Initiation of a medical standing order is an action that requires nursing documentation. This section provides a guide to public health nursing (PHN) documentation based on best practices and professional nursing standards. This section is not comprehensive, and PHN departments should review additional requirements that may be necessary for compliance with specific accrediting bodies, state regulations, facility policy or reimbursement entities (such as a private insurer or state Medicaid) because these may vary from facility to facility. It is important that standing order policies and protocols include acceptable means of “authenticating” (defined as linking the medical order with the patient care delivered by the public health nurse) orders. It may be acceptable to offer more than one authenticating method for users. This should be determined by each PHN department with input from Area nurse, PHN consultant, health information management, billing staff, risk manager, compliance officer, and clinical medicine staff. Please see Section 5.8 below for resources to assist in development of policies and procedures for standing orders. Clinics and hospitals should refer to IHS, Tribal, state, facility, and accreditation policies and regulations for additional guidance. 5.1 What Is a PHN Medical Standing Order? There are two kinds of PHN medical standing orders. One is an individual, patientspecific standing order, and the other is a non-patient-specific standing order. The former is an instruction for a patient’s care under specified circumstances. The latter is an instruction for patient care under specified circumstances, which the public health nurse is to follow for all patients unless the attending physician intervenes with different instructions. Example of an Individual, Patient-Specific Standing Order The medical provider orders a PHN consult in the Electronic Health Record (EHR) and asks the public health nurse to provide three weekly weights on a premature infant. The medical provider also asks the public health nurse to assess home infant feeding, amounts and frequency, at each of the three weekly visits. This medical order only applies to a specific patient. Indian Health Service Page 5-1
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Public Health Nursing Documentation Guidelines - Indian Health ...

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