• For the purposes of this data element, an ED admit is any patient who receives treatment, care or evaluation in the ED.
• Pneumonia need not be the primary or only diagnosis.
• For the purpose of this data element, the "ED form" is the document within the ED record which contains the final diagnosis/impression.
• For patients admitted to observation from the ED, who later result in inpatient status, a diagnosis/impression of pneumonia must be documented while the patient was in the ED, using the following guidelines.
• Do not use medical student, intern, resident, attending physician/APN/PA, etc. documentation of a differential diagnosis.
• Only select “4” if there is a place in the ED chart to document the final ED diagnosis/impression and this area is left blank. However, if there are multiple areas to document the final ED diagnosis/impression and any are completed, do not select “4”.
• Diagnosis of pneumonia cannot be taken from the chest x-ray, discharge summary, coding or billing documents, or face sheet.

• If pneumonia is listed as the final diagnosis/impression on the ED form by any physician/APN/PA, select “1.” No further review of additional suggested data sources is needed (e.g., the admit order or admit note.)
• If the same emergency room physician/APN/PA who completed the ED forms did not include pneumonia as a final diagnosis or impression but completes an admit note or order with an admission diagnosis of pneumonia or a Pneumonia Pathway or equivalent, select “1.”
  Example:
  • The emergency room physician/APN/PA completes the ED form and the final diagnosis or impression is not pneumonia.
    -If that same physician/APN/PA wrote the admit orders or admit note with a diagnosis of pneumonia, select “1.”
    -If the admit orders or admit note completed by that same physician/APN/PA does not include a diagnosis of pneumonia, select “3.”

• If pneumonia is listed as the final diagnosis/impression on the ED form by any physician/APN/PA, select “1.” No further review of additional suggested data sources is needed (e.g., the admit order or admit note.)
• If the hospitalist, attending physician/APN/PA or consultant who completed the ED forms did not include pneumonia as a final diagnosis or impression but completes an admit note or order with an admission diagnosis of pneumonia or a Pneumonia Pathway or equivalent, select “1.”
  Example:
  • The hospitalist, attending physician/APN/PA or consultant comes to the emergency room and completes the ED form, and the final diagnosis or impression is not pneumonia.
    -If that same physician/APN/PA wrote the admit orders or admit note with a diagnosis of pneumonia, select “1.”
    -If the admit orders or admit note completed by that same physician/APN/PA does not include a diagnosis of pneumonia, select “3.”

• A History & Physical can be used ONLY if the physician/APN/PA documents on one of the ONLY ACCEPTABLE SOURCES to “see H&P.”
• If pneumonia is documented as a diagnosis/impression on ANY of the ONLY ACCEPTABLE SOURCES, select “1”.
• Any of the ONLY ACCEPTABLE SOURCES can be used without a date or time.
• Those cases where the patient is seen in the emergency department but the medical record does not contain an ED form, which is different than just leaving the form blank (e.g., the physician treating the patient in the ED documented everything on an admit note,) are limited to the following ONLY ACCEPTABLE SOURCES: Admitting notes, Admitting physician orders.
• If the admit orders refer to a Pneumonia Pathway or equivalent, or the Pneumonia Pathway contains orders to admit, select “1.”

Pneumonia Diagnosis on Admission-Direct Admit

• For the purposes of this data element, a direct admit is any patient who does not receive treatment, care or evaluation in the ED.
• For patients who are a direct admit to observation, who later result in inpatient status, a diagnosis/impression of pneumonia must be documented upon admission to observation.
• Pneumonia need not be the primary or only diagnosis/impression but included in the ONLY ACCEPTABLE SOURCES as a diagnosis/impression.
• If pneumonia is documented as an impression/diagnosis on ANY of the ONLY ACCEPTABLE SOURCES, select “2”.
• Any of the ONLY ALLOWABLE SOURCES can be used without a date or time.
• A History & Physical can be used ONLY if the physician/APN/PA documents on one of the ONLY ACCEPTABLE SOURCES to “see H&P”.
• If the admit orders refer to a Pneumonia Pathway or equivalent, or the Pneumonia Pathway contains orders to admit, select “2.”
• Diagnosis of pneumonia cannot be taken from the chest x-ray, discharge summary, coding or billing documents, or face sheet.

PHYSICIAN/APN/PA DOCUMENTATION ONLY

• Emergency Department
  • ED admitting notes
  • ED history and physical
  • ED physician orders
  • ED record
• Direct Admit- ONLY ACCEPTABLE SOURCES
  • Admitting notes
  • Admitting physician orders
  • Physician admission note