Question

What POA indicator would you use for the following scenario?

A 45 year old female presents to the ER with shortness of breath, cough and a high fever. The ER doctor gets a chest x-ray which indicates pneumonia so he admits the patient. Shortly after admission the patient deteriorates and develops sepsis. In his discharge summary the doctor indicates the patient's diagnoses as sepsis secondary to pneumonia, organism unknown. A query of the physician indicates it is unknown if the patient was septic prior to admission. What POA indicator would you assign for sepsis?

a. Y
b. N
c. W
d. U

Answer 1

The POA indicator for sepsis in the case of the patient is 'U' as it is unknown and insufficiently documented whether the sepsis was present at the time of admission.

Step-by-step explanation:

In the scenario described where a 45 year old female patient presents to the Emergency Room (ER) with shortness of breath, cough, and a high fever, and is later admitted with pneumonia prior to the development of sepsis, the appropriate Present on Admission (POA) indicator for sepsis would be 'U' (documentation is insufficient to determine if the condition was present at the time of inpatient admission). The POA indicator 'U' signifies that it is unknown whether the condition was present at the time of inpatient admission, and the documentation is insufficient to determine whether it was present on admission or not. As the physician indicated it was unknown if the patient was septic prior to admission, 'U' is the most appropriate POA indicator to assign to the diagnosis of sepsis.