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Documentation Tip of the Week: Present on Admission

Posted on Wed, Jun 17, 2015
Documentation Tip of the Week: Present on Admission

Documentation tips for clinicians. Remember, ICD-10 takes effect October 1, 2015. 

A diagnosis cannot be the main reason for admission, the Principal Diagnosis, unless it is present on admission.

Please document if there is a “Possible” diagnosis (eg possible sepsis) at the time of admission.

Did You Know? Hospital Acquired Conditions (HACs) – Hospitals are not paid additional monies for certain medical conditions that occurred during the hospitalization. Please document these conditions in the H&P so there is clear documentation that the condition was PRESENT ON ADMISSION

Examples of HACs:

  • Cath associated UTI
  • Manifestation of poor glycemic control eg DKA
  • Vascular cath infection
  • Falls/trauma
  • Blood Incompatibility
  • Foreign object retained after sugery
  • Stage 3/4 pressure ulcer
  • DVT & PE after ortho procedure
  • Fractures
Remember hospital documentation can include “possible, probable or suspected” diagnoses

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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