Dr. Townsend,

Are you saying that nursing notes may be utilized to determine infection or 
suspicion of infection for abstraction?

Dale DeLude
P.I. Specialist
Advocate Condell Medical Center
801 S. Milwaukee Ave.
Libertyville, IL 60048
Telephone:  847-990-5863
Fax:  847-573-4251
[email protected]

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-----Original Message-----
From: Sepsisgroups [mailto:[email protected]] On 
Behalf Of Townsend, Sean, M.D.
Sent: Sunday, October 18, 2015 9:32 AM
To: Karen Young
Cc: [email protected]
Subject: Re: [Sepsis Groups] Documentation source for suspicion of clinical 
infection

Yes, you need to look at all notes from nursing as well.  Simply relying on md 
documentation will be too late.

On Oct 18, 2015, at 7:08 AM, Karen Young 
<[email protected]<mailto:[email protected]>> wrote:

Please share what data source your organization is using for a date/time stamp 
for suspicion of clinical source of infection.  Are you using an RN progress 
note time? How specific about suspicion are you requiring in documentation? 
Have you standardized the question to a yes or no?

Our ED physicians say their Note Time does not reflect suspicion time as a 
Severe Sepsis criteria fulfilled, because progress notes are opened before labs 
are resulted or exams performed.  File Time of the note is several hours after 
the care is delivered and using that time admittedly would not drive early 
treatment.
>From where are you taking a date/time stamp for physician diagnosis or 
>suspicion?

Karen Young RN CPHQ
QI Specialist
Valley Medical Center
Renton WA 98055
425-228-3440 ext 5963
[email protected]<mailto:[email protected]>


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