Ask the expert: Identifying patients with present on admission conditions
Staff Development Weekly: Insight on Evidence-Based Practice in Education, August 21, 2009
Want to receive articles like this one in your inbox? Subscribe to Staff Development Weekly: Insight on Evidence-Based Practice in Education!
This week, June Marshall, RN, MS, NEA-BC, discusses how to properly document catheter-associated urinary tract infections (CAUTI) as present on admission (POA).
Q: How do we document whether a patient's CAUTI was hospital-acquired or POA?
A: As patients enter your organization, assessments and appropriate actions should be taken regarding patients who are symptomatic for urinary tract infections (UTI). Having the appropriate tests completed to be able to document that the patient's UTI was POA saves the organization from being held accountable for a CAUTI in cases where the patient presents with a catheter in place or requires catheter placement shortly after admission.
POA conditions are determined with the following criteria:
- There must be clear differentiation in the presence of diagnosis/condition at time of admission or development of the problem after admission.
- Physician documentation of the condition must exist in the patient's medical record. If POA, it must be documented concurrently with the physician's admission orders.
- Primary responsibility for complete and accurate documentation lies with the physician/licensed independent practitioner.
- Any incomplete documentation requires provider clarification.
Have a question for our experts? E-mail your queries to Senior Managing Editor Rebecca Hendren at rhendren@hcpro.com. See your name in print and find answers to your questions.
Want to receive articles like this one in your inbox? Subscribe to Staff Development Weekly: Insight on Evidence-Based Practice in Education!
Related Products
-
Hospital Safety Center
Improve compliance with hospital safety standards from The Joint Commission, OSHA, and other regulators with this...
-
Healthcare Life Safety Compliance
Learn Life Safety Code tips and interpretations for healthcare facilities with this in-depth monthly resource.
-
CNA Training Advisor: Lesson Plans for Busy Staff Trainers
Finally-a staff training program that really works!
-
Medical Environment Update
Timely medical compliance news from OSHA, CDC, EPA, and other regulatory agencies!
-
Bloodborne Pathogens Training Video
Meets OSHA requirements for training employees on the bloodborne pathogens standard!
Most Popular
- Articles
-
- HIPAA Q&A: Flu shot requirement for hospital employees
- HealthDataInsights posts new issues for medical necessity claims
- Running an effective peer review committee meeting
- Q&A: Incidental disclosures and patient privacy
- Sneak Peek: Effort underway to establish caseload benchmarks
- New FAQ posted on storing laryngoscope blades
- Tip: Perform your own internal investigation prior to government audit
- What does case-mix index mean to you?
- HIPAA 5010 deadline extended, but threat remains, says AMA
- HHS task force: Consider privacy, security with text messages
- E-mailed
-
- Running an effective peer review committee meeting
- HIPAA Q&A: Flu shot requirement for hospital employees
- What does case-mix index mean to you?
- HHS task force: Consider privacy, security with text messages
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Tip: Correctly code bilateral pain management procedures
- 2012 CPT code changes for ASCs: Shoulder and knee scopes and pain management
- COT basics to best
- Documentation and coding for toxic metabolic encephalopathy
- Guidance and tact key to compliant, effective physician queries
- Searched