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CMW Tip of the Week: Improve POA documentation

Case Management Weekly, September 24, 2008

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This week’s tip, an ask the expert, is provided by June Stark, RN, BSN, MEd.

Q: What are some strategies to improve physician documentation of present-on-admission (POA) conditions?

A: The strategic plan for capture of POA and accurate documentation can comprise one or more of the following interventions:

• Physician educational sessions to teach about POA diagnosis and documentation requirements.
• Physician query sheets left in the chart by the case manager. These documents can request clarification of a POA diagnosis or another documentation etiology. The physician should use these as an opportunity to document and clarify a patient’s diagnosis to ensure the appropriate documentation follows the patient through the continuum of care.
• Case management/documentation specialist meetings held with physician leadership monthly or quarterly. These meetings can be used to further educate staff and discuss outcomes of documentation improvement programs and areas for improvement.
• Physician incentive programs to support accurate documentation. Recommend to hospital administration that such programs be established.
• Periodic chart review, in collaboration with the coders, to learn about POAs captured and those missed, as ongoing assessment of the documentation opportunities. Results are shared with case managers, documentation specialists, and physicians.

Have a tip you’d like to share? Or maybe a question for our experts? Email it to editor jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!

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