I'm reviewing the additional notes for abstraction for v 5.1 and I have a couple questions. First, in the spec manual, it states "do not use evidence of organ dysfunction that is considered to be due to a chronic condition or medication (e.g., creat >2 for ESRD, INR > 1.5 for pt on warfarin, decrease in SBP associated with administration of a BP med). However, in the additional notes for abstraction, we are told to not use SIRS criteria or a sign of organ dysfunction if there is physician/APN/PA documentation that it's due to a chronic condition, normal for the pt, not due to an infection, or due to a medication. We are not to infer-documentation is needed. In the past we were allowed to not use the ESRD and INR criteria without physician/APN/PA documentation. Has that changed with these guidelines?
Second, the additional notes states that we should not review antibiotic doses given >72 hours prior to severe sepsis presentation. So does that mean, for example, if a pt develops severe sepsis on 8/10 at 0800, and the pt received Rocephin 8/6@ 1000, 8/7 1000, 8/8 1000, 8/9 1000 and 8/10 at 1000, we would pick 8/7 1000 since that's the earliest antibiotic in the prior 72 hours? Thank you. Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center 484-476-8092 Pager: 5240
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