Health Information Management

Topic: Educate clinical staff to improve your hospital’s reporting of POA indicators

HIM-HIPAA Insider, October 23, 2007

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Present on admission (POA) refers to those conditions present when staff members issue an order for an inpatient admission. POA also encompasses conditions that develop during an outpatient encounter, including emergency departments, observation, or outpatient surgery.

Coders require thorough clinical documentation from the beginning of the patient encounter at hospital facility, regardless of whether the patient was admitted through the ED or via a direct admit to the inpatient setting. This will ensure correct POA assignment.

For those patients who present to the ED, it is imperative that the ED physician describe in complete detail the patient's presenting signs and symptoms, as well as each sign and symptom's relationship to provisional diagnoses. The majority of the time, the ED physician's documentation sets the tone for the attending physician's documentation because it serves as a reference and starting point for the admitting note and history and physical assessment.

Editor's note: For more information, click here.

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