Public Health Nursing Practice Manual
Guidance for the Public Health Nursing Assessment*
Industry or Outbreak
For those individuals who are screened in an industry/group and not transferred to the district of residence (DOR) for follow-up, there is no requirement that they automatically receive a PHN Assessment by the DOR. The PHN in charge of the industry follow-up makes a case-by-case referral to the DOR of any contact who, in her/his judgment, is in need of and could benefit from a complete PHN Assessment of contact and household. In such a case, the PHN in charge of the industry writes a progress note to refer to the DOR explaining the reason for the referral and why a PHN Assessment is warranted. The PHN of the DOR of the contact will initiate a PHN Assessment and note in the comments section on the intake page in NPMS the PF # and location of the medical record of the index client, if there is one.
List the Health Need/Goals that the PHN assessed. These may be those that the PHN identifies, those that the member identifies or those that the PHN identifies jointly with the member. Each problem identified in the assessment should have a health need/goal listed.
For each health need/goal identified, check off the action/intervention given to the family and check off where the member(s) was referred as appropriate. Document follow-up of an action/intervention (referral) in the Plan (health need/goal) section on subsequent encounters. Check “other” and write in any other referrals made that are not on the list.
Check off any anticipatory guidance that the PHN gave to the family. Use this section to document advice that the PHN gave not related to a health need/goal identified in the assessment. For example, if the members all have a healthy diet but the PHN still reinforces the importance of folic acid or healthy diet choices with the family, the PHN would check it off here. Or if a member is pregnant and the PHN wants to advise about bottle caries, the PHN would check it off here. Write in the comments section any additional comments about the plan for this family.
See NPMS Manual Section Encounter/Disposition Part 2 # 3 for additional information. If a client/family requires more than four (4) encounters to assist with the identified health goals/needs (not related to the original referral), close Level 2 in NPMS and enter the date and purpose of the next encounter in the text box. Open a medical record, print a copy of the PHN Assessment and place the Assessment in the Miscellaneous section of the chart. Continue to document in the medical record progress notes utilizing the SOAP format.
Printing and Filing
Print and file a copy of the PHN Assessment in a local health center/program file per the health center/program procedure. If the index case or any household members have a chart, put one copy in the miscellaneous section of
each chart. *See NPMS manual for detailed instructions on completing the PHN Assessment module
© 2007 LAC DPH Public Health Nursing