FYI from QNet

Pamela Anderson, BSN, RN
Clinical Data Abstractor
Interim Sepsis Coordinator
Loyola University Health System
Center for Clinical Excellence
Maguire Center | Bldg 105-3909 | Maywood, IL 60153
(O) 708-216-5544 | (F) 708-216-7867 | (E) 
[email protected]<mailto:[email protected]>

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From: IQR Q&A System [mailto:[email protected]]
Sent: Friday, March 25, 2016 3:12 PM
To: PAMELA J. ANDERSON
Subject: Reassessment documentation all in one note? [Incident: 160301-000101]



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 Subject

Reassessment documentation all in one note?



 Discussion Thread

 Response Via Email (Jennifer Witt)

03/25/2016 04:12 PM

The documentation of the components of the focused exam (cardiopulmonary exam, 
skin exam,Capillary Refill exam, etc.) could be documented on different sources 
and still be acceptable.


I hope this helps.

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



 Auto-Response

03/01/2016 03:38 PM

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://cms-ip.custhelp.com/app/answers/list/c/576> 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

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 (Pamela Anderson)

03/01/2016 03:38 PM

For the reassessment of volume status and tissue perfusion, the specifications 
state that all the vital signs are required to be in one note, but does that 
note also need to include the other elements of cardiopulomonary, capillary 
refill, pulse, and skin findings OR can the remaining elements be found in 
other provider notes in the same time frame?



 Question Reference #160301-000101

Escalation Level:

5 Business Days

Product Level 1:

Measures & Data Element Abstraction

Category Level 1:

Hospital Inpatient - Sepsis

Category Level 2:

Cardiopulmonary Evaluation Date and Time

Date Created:

03/01/2016 03:38 PM

Last Updated:

03/25/2016 04:12 PM

Status:

Resolved (IP only)

Discharge Period:

10/01/2015 - 06/30/2016




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