FYI- I just received a response back regarding the use of a Sepsis orderset and/or an antibiotic with an indication for infection/ sepsis as a means for being able to prove documentation of infection by a provider, so I thought I would share.
Have a great day! ~Claudia Claudia Orth BSN, RN, CCRN-K Regional Sepsis Coordinator Clinical Quality Munson Medical Center 1105 Sixth Street Traverse City, MI 49684-2386 (231) 935-5692 (Voice) (231) 318-0394 (Pager) [email protected]<mailto:[email protected]> From: IQR Q&A System [mailto:[email protected]] Sent: Wednesday, March 30, 2016 11:37 AM To: Orth, Claudia Subject: SEP-1- Documentation of Infection [Incident: 160307-000035] Recently you requested personal assistance from our on-line support center. Below is a summary of your request and our response. If this issue is not resolved to your satisfaction, you may reopen it within the next 1095 days. Thank you for allowing us to be of service to you. To access your question from our support site, click here.<https://urldefense.proofpoint.com/v2/url?u=https-3A__cms-2Dip.custhelp.com_app_account_questions_detail_i-5Fid_283165&d=BQMFAw&c=NjMSpGk2_ZA7ZXEWULsqPkmhl_68_j_HpnUZ-YvUJ78&r=dtp2T-Kko33TS6Sl7iEnNQ&m=tpop855VPl-rZFKZ2Om2Hik-SYqEDZRwkF1EnELBVMg&s=Uo5JlocL9HUX2jGYY3l6pWp6HOTvVNB7ggXSmkNmIVE&e=> Subject SEP-1- Documentation of Infection Discussion Thread Response Via Email (Char Teed) 03/30/2016 11:36 AM Hello Claudia, First paragraph question: yes that can be used as a suspected infection. Sepsis is acceptable as an infection. Response Via Email (Lisa Lihs) 03/08/2016 07:53 AM Due to the volume of inquires related to the SEP-1 measure we are experiencing a response lag time. Responses to SEP-1 questions are being answered daily. Please be reminded that Q&As are available in the QualityNet knowledge base tool<https://urldefense.proofpoint.com/v2/url?u=https-3A__cms-2Dip.custhelp.com_app_answers_list_c_576&d=BQMFAw&c=NjMSpGk2_ZA7ZXEWULsqPkmhl_68_j_HpnUZ-YvUJ78&r=dtp2T-Kko33TS6Sl7iEnNQ&m=tpop855VPl-rZFKZ2Om2Hik-SYqEDZRwkF1EnELBVMg&s=IGg5zYaTp-g63-z7SLtQdCeWx_bEsIrApHPM8AlwQnU&e=> posted on QualityNet. The Sepsis (SEP-1), Additional Notes for Version 5.0b Abstraction are available on QualityNet https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier3&cid=1228774725171<https://urldefense.proofpoint.com/v2/url?u=https-3A__www.qualitynet.org_dcs_ContentServer-3Fc-3DPage-26pagename-3DQnetPublic-252FPage-252FQnetTier3-26cid-3D1228774725171&d=BQMFAw&c=NjMSpGk2_ZA7ZXEWULsqPkmhl_68_j_HpnUZ-YvUJ78&r=dtp2T-Kko33TS6Sl7iEnNQ&m=tpop855VPl-rZFKZ2Om2Hik-SYqEDZRwkF1EnELBVMg&s=VyINo7zivXunV9JA-_WvgQHvkWMNibfT03HpVYWuMTQ&e=> Be aware, while the Additional Notes for Abstraction were released on 2/10/2016 they are effective with cases discharged starting 10/1/2015. The decision to re-abstract cases abstracted prior to release of the Additional Notes for Version 5.0b is up to the individual facility. Please close your question if it is answered by these resources. We will continue working diligently to reduce response lag time in replying to questions. Customer By Web Form (Claudia Orth) 03/07/2016 11:01 AM Can a Sepsis order set with an order for example for an antibiotic that states "indication for infection/sepsis" be used as the date/time of documented suspected infection? Our providers are often documenting outside of the 6 hour window where we are looking to align all criteria for severe sepsis being present. In those cases if there is no nursing documentation related to suspected or documented infection, we are working with skewed data, since they will have met all the other criteria and had the orders including 3 and sometimes 6 hour bundles implemented but the actual documentation comes later. The providers insist that it is more important to recognize the patient is septic and physically treat/care for them, then to stop what they are doing to go sit down and dictate or document said infection and treatment. It's unreasonable to expect them to then think back and state date/time frames for when they came to the diagnosis or suspicion of infection. Any and all assistance you may be able to provide would be greatly appreciated. Question Reference #160307-000035 Escalation Level: 5 Business Days Product Level 1: Measures & Data Element Abstraction Category Level 1: Hospital Inpatient - Sepsis Category Level 2: Septic Shock Presentation Date and Time Date Created: 03/07/2016 11:01 AM Last Updated: 03/30/2016 11:36 AM Status: Resolved (IP only) Discharge Period: 10/01/2015 - 06/30/2016 [---001:002521:56901---]
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