Diagnosis in ED not documented during Admission
We recently had a case where the ED provider stated "Sepsis and Pneumonia" on the ED note. However, when the Admitting provider wrote the H&P he stated UTI d/t Foley with no mention of Pneumonia or Sepsis. Throughout the documentation, during the patient's visit, the only mention of Sepsis and Pneumonia was in ED without clinical indicators. I spoke with the Admitting provider who will not add R/O for the diagnoses. The ED provider is adamant that those were the diagnoses while the patient was in ED.
Can someone help me....is anyone having this issue? Should the ED provider change their documentation or should the Admitting provider add ruled out?
Any information would be greatly appreciated!