We have reviewed the new Sepsis requirements and according to the requirements, the MD/PA/NP must document the results of the capillary refill, cardiopulmonary exam, peripheral pulse exam and skin exam so I'm not sure the documentation by nurse will meet this requirement. In addition, the passive leg raise exam must be performed/documented by MD/PA/NP as well.
Thanks, Mary Ann David, MSN, RN, CNS, ACNS-BC Clinical Nurse Specialist, MICU/SICU Sharp Chula Vista Medical Center Tel. No. 619-502-3165 Hospital Cell No. 619-502-5578 Pager No. 619-688-7124 Fax. No. 619-502-4076 Email. [email protected]<mailto:[email protected]> A Clinical Nurse Specialist (CNS) is a Masters prepared Advance Practice Registered Nurse whose function is to improve outcomes in patient care. Functioning in 5 sub roles including: Expert in Clinical Practice, Educator, Leader, Researcher, and Consultant, we influence our 3 spheres of practice: Patient Care, Nursing, and Systems. รพ*Think GREEN before printing this e-mail. CONFIDENTIALITY NOTICE: The information transmitted in this e-mail is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material, including 'protected health information'. If you are not the intended recipient, you are hereby notified that any review, retransmission, dissemination, distribution, or copying of this message is strictly prohibited. If you have received this communication in error, please destroy and delete this message from any computer and contact me immediately at (619) 502-3165 or by return e-mail to [email protected]<mailto:[email protected]>. From: Sepsisgroups [mailto:[email protected]] On Behalf Of [email protected] Sent: Wednesday, May 27, 2015 12:25 PM To: [email protected] Subject: [Sepsis Groups] CMS Guidelines So, I've read through the new CMS Guidelines and it states that a repeat assessment must be completed within 6 hrs with either a focused exam (including VS, cardiopulmonary exam, cap refill, peripheral pulse eval and skin exam) or any two of the four: CVP, SV02, bedside cardiovascular ultrasound, passive leg raise or fluid challenge. At our hospital, we have the "shift evaluation" and "shift re-evaluation." If the nurse documents the "shift re-evaluation" they are basically saying nothing has changed since the last evaluation. I'm wondering if that will suffice, or if they actually have to do another complete head-to-toe assessment. Any thoughts?? Thanks, Debbie Debbie Chambless, MSN, RN, ARNP-C Sepsis Coordinator Osceola Regional Medical Center Kissimmee, Fl 34741 Office: 407-518-3949 Cell: 772-807-0525 ~~Recognizing sepsis as a global enemy. Hoping for global unity in finding a solution~~ [cid:[email protected]]
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