HOSPITAL-ACQUIRED CONDITIONS
How It Pertains To Documentation Needs
And Present On Admission (POA)
URINARY CATHETER ASSOCIATED urinary tract infection (UTI)
 Things to look for:
o Documentation of UTI or clinical evidence of UTI and/or systemic
infection
o Presence or absence urinary catheter on admission (check nursing
home documents, nursing assessments, etc.)
 Documentation needs:
o Is the UTI related to the urinary catheter? Is it POA?
o Is there related systemic infection? Is it POA?
Coder clinical notes:
 The use of urinary catheters in both men and women who are elderly,
people experiencing nervous system disorders, and people who are
convalescing or unconscious for long periods of time may result in an
increased risk of UTI for a variety of reasons. Scrupulous aseptic
technique may decrease this risk.
 The use of urinary catheters may physically disturb the protective lining of
the urinary organs, thereby allowing bacteria to invade the exposed
epithelium.
PRESSURE ULCERS
 Things to look for:
o Documentation of ulcer or clinical evidence of ulcer
o Presence or absence of ulcer on admission (in nursing home
documents, nursing skin assessments, etc.)
 Documentation needs:
o What type of ulcer and/or etiology? (e.g., pressure ulcer, venous
stasis ulcer, diabetic ulcer, etc.)
o Is the ulcer POA?
o Is the ulcer infected? If so, was it localized or systemic? Was the
localized or systemic infection POA?
Coder clinical notes:
 Bedsores are caused by three different tissue forces:
o Pressure, or the compression of tissues. In most cases, this
compression is caused by the force of bone against a surface.
o Shear force, or a force created when the skin of a patient stays in
one place as the deep fascia and skeletal muscle slide down with
gravity. This can also cause the pinching off of blood vessels which
may lead to ischemia and tissue necrosis.

o Friction, or a force resisting the shearing of skin. This may cause
excess shedding through layers of epidermis.
Other conditions, such as excess moisture from incontinence, perspiration
or exudate, may aggravate the situations. Additional factors in the
development of bedsores include age, nutrition, vascular disease,
diabetes mellitus, and smoking, as well as a variety of others.
VASCULAR CATHETER ASSOCIATED INFECTION
 Things to look for:
o Documentation of infection or clinical evidence of localized infection
or systemic infection (check nursing home documents, nursing
assessments, etc.)
o Presence of vascular catheter on admission
 Documentation needs:
o Is there a localized infection associated with presence of vascular
catheter? Is it POA?
o Is there a related systemic infection? Is it POA?
Coder clinical notes:
 Two types of infection may develop: skin infection at the catheter or port
insertion site and/or bloodstream infection.
 Although vascular catheters provide necessary vascular access, their use
puts patients at risk for local and systemic infectious complications,
including local site infection, catheter-related blood stream infection, septic
thrombophlebitis, endocarditis, and other infections (e.g., lung abscess,
brain abscess, osteomyelitis, and endophthalmitis).
SURGICAL SITE INFECTION
 Things to look for:
o Documentation or clinical evidence of systemic or localized
infection
o Documentation of a recent surgery
 Documentation needs:
o Is there a localized infection associated with surgical site? Is it
POA?
o Is there an infection associated with a device or implant? Is it POA?
o Is there a related systemic infection? Is it POA?
o Are there any complications during the surgical procedure itself
leading to the infection?
Coder clinical notes:
 Surgical site infections (SSI) can be either incisional or involve an
organ/space. Incisional SSIs can involve only skin and subcutaneous
tissue or can involve deeper soft tissues of the incision. Organ/space SSIs
involve any part of the anatomy (e.g., organ or space) other than incised
body wall layers that was opened or manipulated during an operation.
OBJECT LEFT DURING SURGERY
 Things to look for:
o Documentation of surgery occurring prior to admission (check
nursing home documents, nursing assessments, etc.)
o Documentation of object inadvertently left during procedure
 Documentation needs:
o Documentation of circumstances
o Is it POA?
o Are there any related complications?
AIR EMBOLISM
 Documentation of or clinical evidence of air embolism
 Documentation needs:
o Documentation of circumstances
o Is this a complication due to an associated device, procedure, etc.?
o Is it POA?
o Are there any related complications?
Coder clinical notes:
 Air embolism can occur whenever a blood vessel is open and a pressure
gradient exists favoring entry of gas. This is one reason why surgeons
must be particularly careful when operating on the brain, and why the
head of the bed is tilted down when inserting or removing a central venous
catheter from the jugular or subclavian veins.
 Trauma to the lung can also cause an air embolism. This may happen
after a patient is placed on a ventilator and air is forced into an injured vein
or artery, causing sudden death.
 Air can be injected directly into the veins either accidentally or as a
deliberate act. Examples include misuse of a syringe, and industrial injury
resulting from use of compressed air. Single air bubbles in a vein do not
stop the heart, due to being too small. However, always exercise caution.
BLOOD INCOMPATIBILITY
 Documentation or clinical evidence of blood incompatibility
 Documentation needs:
o Documentation of circumstances
o Is it POA?
o Are there related complications?
INJURIES
 Things to look for:
o Documentation of injury before admission (check nursing home
documents, nursing assessments, etc.) or occurring after admission
 Documentation needs:
o Documentation of circumstances, type, and mechanism of injury
o Is it POA?
o Are there any related complications?
Source: Stephanie Bland, CSS, lead coder at United Samaritans Medical Center
in Danville, IL submitted this form. Adapted with permission.