Health Information Management

Know where to look in the medical record when assigning the POA indicator

HIM-HIPAA Insider, July 21, 2009

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Certain areas of the patient’s record will most likely provide important clues to the coder that will assist in present on admission (POA)indicator selection. The best places to find POA information are emergency department notes, records from the outpatient department or observation area, the history and physical, the initial physician progress notes, and physician admit orders. Encourage staff members to check these areas first before beginning to review the patient’s entire medical history.

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