Hello, In response to this question:
The answer is just "Sepsis focused exam completed." Or "I performed a reassessment of perfusion (or volume) status." You don't even need to provide vitals. This QNet webpage offers further guidance if needed. https://cms-ip.custhelp.com/app/answers/detail/a_id/165223 The NQF and CMS Measure Stewards ________________________________ From: Sepsisgroups <[email protected]> on behalf of Rutherford, Richard <[email protected]> Sent: Friday, June 9, 2017 12:17 PM To: [email protected] Cc: Vasquez, Ashley Subject: [Sepsis Groups] Sepsis Focused Reexamination 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. ________________________________ CONFIDENTIALITY NOTICE: This email contains information from the sender that may be CONFIDENTIAL, LEGALLY PRIVILEGED, PROPRIETARY or otherwise protected from disclosure. This email is intended for use only by the person or entity to whom it is addressed. If you are not the intended recipient, any use, disclosure, copying, distribution, printing, or any action taken in reliance on the contents of this email, is strictly prohibited. If you received this email in error, please contact the sending party by reply email, delete the email from your computer system and shred any paper copies. Note to Patients: There are a number of risks you should consider before using e-mail to communicate with us. See our Privacy & Security page on www.henryford.com for more detailed information as well as information concerning MyChart, our new patient portal. If you do not believe that our policy gives you the privacy and security protection you need, do not send e-mail or Internet communications to us.
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