As I understand, abstractors are to use the date and time that the provider initiated documentation (progress note, h&p, etc) if using provider documentation to determine Severe Sepsis presentation time. If physician documents @ 0711 "could be severe sepsis as lactic acid is 6.7" but the lactic acid results were not even know until 0742, how is it possible to conclude that the severe sepsis presentation time is 0711? Is it acceptable to exclude the physician note in this circumstance and utilize other concrete clinical data in determining severe sepsis time, i.e. use the 0742 lactic acid result time?
Karen King, RN MSN Quality Management Core Measures Specialist, Lead Lakeview Regional Medical Center 95 Judge Tanner Boulevard Covington, LA 70433 Office: (985) 867-4467 Cell: (985) 788-0585 Fax: (985) 867-4263 Email: [email protected] This email and any files transmitted with it may contain privileged or confidential information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing, or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email or contact the sender at the number listed.
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