POA Status for pressure ulcers

celesteoconnorcelesteoconnor
in Clinical & Coding
What is current practice ? Do you query for POA status  ? Per CDI pocket guide 2018' The provider must document the presence, location and POA status of pressure ulcers. To be honest, in my practice, if the initial nursing note identifies a pressure ulcer-- I have always accepted that it was POA.   I only query for POA of a pressure ulcer  if the documentation is unclear. Thank you for sharing and providing guidance. 
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Comments

  • lprescott1lprescott1
    The provider does not need to state POA- if the record supports the ulcer as POA you can code the status. That said if there is any question because this is a HAC- I would query to assure no one can challenge. I would also suggest that you speak to your coding team to see how they determine POA and work together to identify those areas within the record that can support the presence on admission.
  • olga.desiatkin@pvhmc.orgolga.desiatkin@pvhmc.org

    Laurie, most of the time floor RN identifies and documents pressure ulcer during assessment once patient is on the unit. It could be done hours post admission order.. and in some instances next day... however photos are taken on admission. If RN documents POA status as Yes, but it is not at admission does provider need to be queried for POA status or can we code from RN documentation despite not being done right on admission?

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