Hello All,
We are struggling with compliance with the focused sepsis reexamination and struggling with the interpretation of the rule changes in v5.2. I would appreciate advice on the minimal acceptable documentation to pass this element for septic shock patients. We would like the standardize this documentation for our providers. Would the following be acceptable? VS BP 120/60 HR 110 RR 18 T 98.6 Sepsis Focused Exam Completed. Or do the individual components need to be documented: VS BP 120/60 HR 110 RR 18 T 98.6 Capillary refill evaluation complete Peripheral pulse examination complete Skin examination complete Or do the actual results need to be recorded VS BP 120/60 HR 110 RR 18 T 98.6 Capillary refill evaluation complete: Cap refill 2 seconds Peripheral pulse examination complete: radial pulses strong and symmetric Skin examination complete: skin pink warm dry Thank you, Rick Rutherford, M.D.
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