Colleagues, I made an error in replying to Dr. Allen last week.
I stated at one point that MD documentation of starting the clock took a priority over any other documentation. This was true in the first set of specs, but changed. I need to retract these comments since it was explained to me that an update to the specifications manual changed the rule that MD documentation governs over chart annotation. MD documentation does NOT govern. The specifications indicate to take the earliest documentation indicating the presence of severe sepsis. The reason this was changed from the original specs was because physician documentation of severe sepsis often will be later than when the patient actually presents with severe sepsis and the treatment begins. Since the goal is early treatment for severe sepsis, using the earliest time reflecting that severe sepsis is present is most appropriate. The original specs did state physician documentation takes priority and I was working from this premise. This was removed during revisions that were released May 29 as the current version 5.0a. My apologies for confusion. I would still explain the measure as I have stated it, minus the references to the priority of MD documentation. The comments I made in error were: "***Here, it will be hard for docs. As a doc, you can always start the clock by documenting severe sepsis is present with a time stamp. That's always your choice and the data abstractors are expected to obey that. If you don't, they are going to pull from assorted documentation -- flow sheets nursing mutes, lab reports -- to build the time all elements of severe sepsis were present.***" _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
