The specification manual infers that only physician, APN, or PA documentation can be used in abstracting the criterion of Documentation of Suspected Source of Infection. The way I interpret this is not to use nurse documentation or diagnostic test results (i.e., CXR positive for pneumonia).
The data dictionary for severe sepsis presentation also reads as if this documentation note must be timed within 6 hours of SIRS and organ dysfunction. This doesn't seem right either, as you could initiate treatment for suspected or known pneumonia and if the patient developed severe sepsis >6 hours later without again documenting the suspicion of pneumonia, the case would be thrown out for inclusion in the measure? Sheree Brown MSN, RN, CNL Manager, Performance Excellence Phone: 517 205-4209 ext. 4209 Pager: 517 534-0127 Fax: 517 788-4715 [email protected] -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of Townsend, Sean, M.D. Sent: Sunday, October 18, 2015 10:36 AM To: Rona Capps Cc: [email protected] Subject: Re: [Sepsis Groups] severe sepsis determination Probably you say no, but if you expand the pneumonia search to things like nursing notes for suspicion of infection, not a formal diagnosis, I bet you can get an earlier time. However, if they don't overlap, no big deal -- you are only excluding a chart, not failing the measure. On Oct 18, 2015, at 7:08 AM, Rona Capps <[email protected]> wrote: Please help. The Spec manual states that criteria must be found within 6 hours of each other to qualify for the severe sepsis diagnosis but many charts that I review are delayed in one thing or another. Current chart example that meets specific criteria: 9-22 @ 2121 lactate =2.1 organ dys 9-22 @ 2255 HR = 111 SIR 9-23 @ 1600 documentation of pneumonia Infection 9-24 @ 0550 WBC = 14.3 SIR 9-24 @ 0832 RR = 24 SIR As you can see the time span is great. 2 SIRs, Infection and organ dysfunction all met at 9-24 @ 0550 but did not take place within 6 hours of each other but rather days. Severe sepsis is NOT documented by physician. Do I say NO to severe sepsis question? Thank you Rona Capps, RN Sepsis/VTE/Meaningful Use Quality Coordinator Jackson Hospital Montgomery, AL 36116 [email protected] ************* _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
