Public Health Nursing Documentation Guidelines - Indian Health ...

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