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I'm interested in learning how other MT 6 users are managing the Present on Admission process. Please provide any insights you have on this topic - even if you don't like how it is going, perhaps we can get a good discussion going!

 

Thanks.

Tags: Admission, Present, on

Views: 155

Replies to This Discussion

Christina,

Currently, our nurses document the present on admission indicators as part of an admission screen assessment.  We just went live with PDOC late September 2012, but there is a possibility of moving the Present on admission queries to the History and Physical templates.  Currently, there is a chance that a provider may not document a history and physical, if the patient has a short stay, or if an Office note that qualifies as a History and Physical is sent over.  Until we can make sure that the queries would be documented by physicians, we will continue to have nursing do this.

 

We have required a Yes/No query that asks if a patient presents with any of the following conditions. If the query is answered yes, then all of the POA queries are required. I could tweak the rule to only require at least one of the queries if the first required query is answered YES, but I haven't had too many complaints so far.

 

Thanks,
Megan

Megan,

Thank you very much for your response! I will share this information among our team.

Regards,
Christina

Hi CHristina,
We currently don't have a section for present on admission, we just made each documentation section on the admission assessment a head to toe assessment then for instance in the Gu section we placed a query Foley cath in place on admission to facility with a Yes No response if Yes it triggers the interevention for Cath Care and sends a consult to the infection control nurse and ask the date and time placed... Same with skin etc.However as we are attempting to meet meaningful use I am going to have to ask if Dvt present on admission so we r thinking of doing the same with that query and adding it into the VTE risk assessment. I guess it is a present on admission query I just don't have it in a specific section that staes present on admission.
Twila

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