Strategy: Analyze various parts of the medical record to determine present on admission (POA) status
CDI Strategies, July 10, 2008
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Where can CDI specialists find POA information in the medical record? Several documents can help decipher POA information, including the following:
- ED notes: ED notes may state the patient’s condition in the workup.
- Admission orders: Sometimes physicians document diagnoses on their admission orders. Ask the physician to clarify the patient’s admission status (i.e., outpatient, observation, or inpatient) associated with any admission order. Watch for any orders in which a physician asks to change the patient’s status, and inquire into the medical necessity for that change. Not only will this assist with proper reporting of POA indicators, but it will also support the principal diagnosis selection.
- H&P: A patient’s condition may be diagnosed or found in the workup of the H&P portion of the physician exam notes. Past medical history as well as current medications may be found here as well.
- Progress notes: Progress notes are a follow-up on a patient’s initial condition diagnosis. These notes may also reveal new findings of existing conditions.
The above excerpt is from The Present On Admission Training Handbook: Answers to Your Coding and Documentation Questions. For more information, please click here.
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