Hello All, Based on the initial question from Karen King... Is it acceptable for the physician or APRN to document the cap refill and peripheral pulses in his reassessment note based on values obtained from nursing documentation?
The measure is specific that the physician performs these. I assume that is ensures the physician is at the bedside looking and touching the patient for their reassessment. I would think the physician can perform their own peripheral pulse and capillary refill exam. They should not need to take it from the nurses notes. [cid:[email protected]] [cid:[email protected]] For the vital signs - it says "was a vital signs review completed..." They can ask the nurse to get a set of complete vital signs and use/review those vitals. [cid:[email protected]] Regardless if we agree or not, unfortunately, this is what CMS has mandated and they are pretty clear. Brenda :) Brenda Downs MSN, APRN, ACNS-BC Cell: 480-622-8103 Program Director Clinical Performance Improvement - ICU Care [cid:[email protected]] From: Sepsisgroups [mailto:[email protected]] On Behalf Of Seckel, Maureen M Sent: Friday, March 25, 2016 10:40 AM To: Al Minjock; [email protected] Cc: [email protected] Subject: Re: [Sepsis Groups] Focused Reassessment Hi to all but this makes no sense to me. Which I understand is not always a relevant statement when working with Sep 1........ If the provider is evaluating the information and documenting, it doesn't matter or shouldn't matter who did it. The provider does not do the Vital Signs, CVP, draw the ScvO2 but is expected to put it together in a note evaluating volume status whichever option they choose. Maureen A. Seckel, APRN, ACNS-BC, CCNS, CCRN, FCCM Lead CNS Medical Pulmonary Critical Care Sepsis Coordinator Christiana Care Health System 4755 Ogletown-Stanton Road 3E29 Newark, DE 19718 Office 302 733-6023 [email protected]<mailto:[email protected]> [cid:[email protected]] From: Sepsisgroups [mailto:[email protected]] On Behalf Of Al Minjock Sent: Tuesday, March 22, 2016 1:18 PM To: [email protected]<mailto:[email protected]> Cc: [email protected]<mailto:[email protected]> Subject: Re: [Sepsis Groups] Focused Reassessment Well.... That's a great question..... SEP-1 really dictates the the evaluation be done in person. So the evaluation should be real time by the MD or APN documenting. Does that help? Sent from my iPhone On Mar 22, 2016, at 1:15 PM, "[email protected]<mailto:[email protected]>" <[email protected]<mailto:[email protected]>> wrote: Is it acceptable for the physician or APRN to document the cap refill and peripheral pulses in his reassessment note based on values obtained from nursing documentation? 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]<mailto:[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. _______________________________________________ Sepsisgroups mailing list [email protected]<mailto:[email protected]> https://urldefense.proofpoint.com/v2/url?u=http-3A__lists.sepsisgroups.org_listinfo.cgi_sepsisgroups-2Dsepsisgroups.org&d=CwICAg&c=2-KPflJYMkCYOVarBpJT1A_HyA_KczLecpJoKSlAsiU&r=Ec4s4j3Ar7JUUsjGyDAznKea23VLQsEkThfyZJwK8nM&m=x2wJwz0pI5peiBWk0kBR0NJOawh6gLQvt_t_sWYL5YU&s=zTXdUwCDxFSQoJ0XbmOzYGanNsCOd6r2E6mmhPrx808&e=
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