Present on Admission Analysis Assignment
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Oakland Community College *
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Course
108
Subject
Health Science
Date
Dec 6, 2023
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docx
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Uploaded by tabbycat22
HIT 108 OC1
FALL 2022
Present on Admission Analysis Assignment
20 Points
CAHIIM Curriculum
AHIMA Entry-Level Competencies for Health Information Management (HIM)
at the Associate Degree Level
Domain
Bloom’s
Level
Entry-Level Competencies
V.
Health Law and
Compliance
5
Evaluate
5
Evaluate
V.3. Identify the components of risk management
related to health information management.
IV.2. RM Evaluate revenue cycle processes
IV.3. RM Evaluate compliance with regulatory
requirements and reimbursement methodologies.
1. Determine the present on admission (POA) status for the following scenarios.
a. A newborn suffers a dislocated shoulder during delivery. What is the POA status indicator for
the shoulder dislocation?
Yes
b. A child fell from the jungle gym at the school playground and was taken to the emergency
room for treatment since she was complaining of pain in her elbow. She was diagnosed with a
supracondylar fracture of the humerus and was taken directly to the operating room. Immediately
after surgery, she experienced severe postoperative nausea and vomiting and was then admitted
as an inpatient for rehydration. Assign the POA status for the:
• Supracondylar fracture- Yes
• Post-op nausea and vomiting- No
• Fall from jungle gym- Yes
2. Determine if the following POA status assignments are correct. If the assigned POA is not
correct, indicate what change should be made to correct the assignment.
a. Physician notes genetic susceptibility for breast malignancy in patient’s record.
Code assigned was Z15.01
POA assigned was Y
Answer: Incorrect, there should be no POA assigned because this code is exempt.
The POA should be blank. Code Z15.01 is expempt from POA reporting.
b. Patient admitted with chest pain. In the progress note of the second day, the physician states
the patient had a mild NSTEMI (non-ST elevation myocardial infarction).
Code assigned was I21.4
POA assigned was N
Answer: Incorrect, the POA assigned should be Yes.
The POA should be Yes due to chest pain being a system of mild NSTEMI.
c. Three days after hip replacement surgery, the physician documents “Rule out pneumonia” in a
progress note after noting fever and cough upon examination. At discharge, the physician
documents pneumonia as one of the discharge diagnoses.
Code assigned was J18.9
POA assigned was Y
Answer: Incorrect, POA assigned should be No.
The POA should be No due to the fever and cough began 3 days after admission.
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