A condition is described in the discharge summary as present on admission, and admission history and physical findings support that it existed at entry. Which POA conclusion follows?
Select an answer to reveal the explanation.
Short Explanation
You get to read the whole chart. If the discharge summary and the admit notes agree the problem was there on arrival, POA Y is fair game—discharge summaries aren't banned from the POA conversation.
Full Explanation
POA determination uses the entire health record. Concordant admission documentation and a discharge summary stating present-on-admission status support POA Y. There is no rule forbidding use of the discharge summary, requiring U merely because multiple documents mention the condition, or omitting POA when findings are repeated at discharge.