You should be able to use the written documentation time as long as it is part of the medical record. Susan Meyerer RN, BSN, CEN, CHCQM Flagler Hospital,St. Augustine Fl 904-819-4765 Nursing Administration [email protected] EXCELLENCE IN NURSING EVERY NURSE. EVERY PATIENT. EVERY TIME
----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of [email protected] Sent: Thursday, January 21, 2016 3:06 PM To: [email protected] Subject: Sepsisgroups Digest, Vol 188, Issue 7 Send Sepsisgroups mailing list submissions to [email protected] To subscribe or unsubscribe via the World Wide Web, visit http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org or, via email, send a message with subject or body 'help' to [email protected] You can reach the person managing the list at [email protected] When replying, please edit your Subject line so it is more specific than "Re: Contents of Sepsisgroups digest..." Today's Topics: 1. Re: [sepsis group] focused exam- septic shock (Belfi, Karen) ---------------------------------------------------------------------- Message: 1 Date: Wed, 20 Jan 2016 14:16:38 -0500 From: "Belfi, Karen" <[email protected]> To: "Osburn, Jennifer R. RN" <[email protected]>, "[email protected]" <[email protected]> Subject: Re: [Sepsis Groups] [sepsis group] focused exam- septic shock Message-ID: <[email protected]> Content-Type: text/plain; charset="utf-8" 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. -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20160120/8ac30f66/attachment.htm> -------------- next part -------------- A non-text attachment was scrubbed... Name: image001.png Type: image/png Size: 40233 bytes Desc: image001.png URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20160120/8ac30f66/attachment.png> ------------------------------ Subject: Digest Footer _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ------------------------------ End of Sepsisgroups Digest, Vol 188, Issue 7 ******************************************** _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
