I need assistance with the source of infection in ER cases. At my facility, our ER physician notes are a dictated ER H&P/Discharge summary. This dictated report will provide a few different times including the initial MD evaluation time, intervention times and dictation time. The issue is when I have to rely on the ER physician to provide the source of infection. The triage screening tool was negative and the radiology studies were negative. The physician notes and assessment may not specifically state if an infection is suspected. I would think my 2 options would be the MD initial evaluation time or the time the MD wrote the admission order with diagnosis of suspected or confirmed infection.
What time are you using in these situations? I believe this situation was discussed in one of the Q&As with a webinar but I cannot find it now. 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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