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Question: Pneumonia diagnosis: ED/Direct Admint

Description: A patient presents as a direct admit for 'dyspnea' per order sheet from the attending physician. The admitting H&P written by the resident, and co-signed by the attending, is in the progress notes greater than 6 hours after arrival and includes pneumonia as a diagnosis.

First Progress note states : “H&P”. There follows a chief complaint of shortness of breath, cough x 7 days, past medical history, review of systems, physical exam ,etc. The final assessment and plan include:

“1. Shortness of breath and cough. Pneumonia, COPD. We will do CXR-pa/lat, sputum culture…..”

Would the answer to Pneumonia Diagnosis: ED/Direct Admit be 2, 3 or 4?

Answer:

According to the specifications for the data element Pneumonia Diagnosis: ED/Direct Admit, the last bullet under the heading for Pneumonia Diagnosis on Admission-Direct Admit states the following "The initial progress note is not an acceptable Data Source and not considered an admission note unless it contains documentation regarding admission". Based on the information provided above in your question, it does not appear that the initial progress note would qualify (however, I do not have the entire note to read), so I would say that value 3 should be selected since the ONLY ACCEPTABLE SOURCES do not indicate pneumonia.

Question Details
Focus area(s): Chart Abstracted Measure Specifications – Clinical
Related documents: PN, Pneumonia Diagnosis: ED/Direct Admit,
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