Ask the expert: Identifying patients with present on admission conditions

Staff Development Weekly: Insight on Evidence-Based Practice in Education, August 21, 2009

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.

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