This, I believe, would be an outlier for vital signs. If the handwritten note had the vital signs written out, you would be compliant. But you can’t take VSS, and the dictated is timed after the 6 hour window.
Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center 484-476-8092 Pager: 5240 [cid:[email protected]] From: Sepsisgroups [mailto:[email protected]] On Behalf Of Osburn, Jennifer R. RN Sent: Monday, January 18, 2016 12:33 PM To: [email protected] Subject: [Sepsis Groups] [sepsis group] focused exam- septic shock I need to know how to document a focused exam when you have a hand written H&P note but the full report, which includes the required information, is not dictated until after the 6 hour timeframe. Would I be able to use the handwritten note date and time for my focused exam? Example- septic shock presentation is 1300. Handwritten note is 1500- states VS stable and includes all other elements required in the focus exam. Dictated H&P is at 2000 which includes the actual VS results- BP, temp, pulse, etc. Thanks Jennifer Osburn, RN, BSN Quality and Accreditation St. Mary's Medical Center 304-526-1506 [email protected]<mailto:mailt:[email protected]> Important Notice: This e-mail message and any attachments are from the above sender at St. Mary’s Medical Center and are intended solely for the individual or entity to which it is addressed and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If you are not the intended recipient of this communication or the employee or agent responsible for delivering the message to the intended recipient, or if it has been sent to you in error, please notify the sender immediately. Do not examine, review, use, disclose, deliver, distribute, reproduce or take any action in reliance on it and immediately delete the message and any attachments.
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