A diagnosis cannot be the main reason for admission, i.e. the principal diagnosis, unless it is PRESENT ON ADMISSION. If contemplating a given diagnosis as the cause of admission, but are not confident that it will materialize, consider documenting it as possible, probable, etc.
Did you know? Hospitals are not paid additional monies for certain medical conditions that occurred during the hospitalization. These are designated as “Hospital Acquired Conditions” (HACs).
Please document all conditions effecting a patient’s care in the H&P so there is clear documentation that those conditions were present on admission avoiding the hospital acquired condition label.
Download the complete tip, Present On Admission (POA).