Health Information Management

Q&A: Present on admission conditions

CDI Strategies, March 17, 2016

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Q: Is a diagnosed and treated condition during the first 24 hours considered present on admission?

A: The definition of present on admission clarifies a diagnosis that was present at the time the admission order was written. In general, many feel a diagnosis that is diagnosed within the first 24 hours of an admission is likely present on admission. Most organizations will easily assign a present on admission status of “yes” for any diagnosis mentioned in the emergency department record or the history and physical. Where it gets a bit shady is when a diagnosis is not mentioned in these two documents, yet appears the following day.

The first step to clarify present on admission is to review the admission assessments and documents. CDI specialists should ask:

  • Were there symptoms to support the presence of this “new” diagnosis?
  • Were there any treatments in place to address this “new” diagnosis?

If you see such information present, then an assignment of a status of “yes” to indicate it was indeed present on admission would likely be correct.

If there appears to be no support for the diagnosis being present on admission, or the support is weak, then query the provider to confirm.  

Certain diagnoses trigger a hospital acquired condition measure, or would greatly affect sequencing, such as sepsis. For these types of cases, I queried the provider to ensure the documentation was crystal clear as to whether it was present on admission.

Many organizations have policies to reflect the assignment of present on admission indicators, and it may be helpful for you to “poll” what is out there. If you are a member of ACDIS and have access to CDI Talk, you may wish to put that question to the group and see what others are doing.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview. 



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