Documentation that the Sepsis Focused Exam Completed that includes a date and time of the documentation, that is sufficient.
Marie Pierce MSN, RN, CCDS Quality Specialist Quality and Resource Management McLaren Bay Region email: [email protected] office phone: (989) 894-3881 McLaren confidentiality statement: "The information contained in this communication, including attachments, is confidential, may be privileged, and is intended only for the use of the named recipient(s). Unauthorized use, disclosure, forwarding or copying is strictly prohibited and may be unlawful. If you have received this communication in error, please notify me IMMEDIATELY at the phone number listed above." -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of [email protected] Sent: Tuesday, June 13, 2017 9:40 AM To: [email protected] Subject: Sepsisgroups Digest, Vol 250, Issue 1 Send Sepsisgroups mailing list submissions to [email protected] To subscribe or unsubscribe via the World Wide Web, visit https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.sepsisgroups.org%2Flistinfo.cgi%2Fsepsisgroups-sepsisgroups.org&data=02%7C01%7Cmarie.pierce1%40mclaren.org%7C418e26dabc654ed0f2ed08d4b261c316%7C82021bda879141b4807aff5b548750e6%7C0%7C0%7C636329580336311866&sdata=GR%2BSg5ozXOm2qrNbzlszPPmhNEL3Y9f7MnvLtnSYOBA%3D&reserved=0 or, via email, send a message with subject or body 'help' to [email protected] You can reach the person managing the list at [email protected] When replying, please edit your Subject line so it is more specific than "Re: Contents of Sepsisgroups digest..." Today's Topics: 1. Sepsis Focused Reexamination (Rutherford, Richard) 2. Re: Sepsis Focused Reexamination (Belfi, Karen) 3. Sepsis Transfers (Carol Groen) ---------------------------------------------------------------------- Message: 1 Date: Fri, 9 Jun 2017 16:17:48 +0000 From: "Rutherford, Richard" <[email protected]> To: "[email protected]" <[email protected]> Cc: "Vasquez, Ashley" <[email protected]> Subject: [Sepsis Groups] Sepsis Focused Reexamination Message-ID: <mwhpr09mb1264561a64cd58181d1bcdb09b...@mwhpr09mb1264.namprd09.prod.outlook.com> Content-Type: text/plain; charset="iso-8859-1" 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. -------------- next part -------------- An HTML attachment was scrubbed... URL: <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.sepsisgroups.org%2Fpipermail%2Fsepsisgroups-sepsisgroups.org%2Fattachments%2F20170609%2Fccbbf12c%2Fattachment-0001.htm&data=02%7C01%7Cmarie.pierce1%40mclaren.org%7C418e26dabc654ed0f2ed08d4b261c316%7C82021bda879141b4807aff5b548750e6%7C0%7C0%7C636329580336311866&sdata=36M6k05GXlfimNymlX4mKujLtQhWsCtgpTnycnwZIvA%3D&reserved=0> ------------------------------ Message: 2 Date: Tue, 13 Jun 2017 07:40:07 -0400 From: "Belfi, Karen" <[email protected]> To: "Rutherford, Richard" <[email protected]>, "[email protected]" <[email protected]> Cc: "Vasquez, Ashley" <[email protected]> Subject: Re: [Sepsis Groups] Sepsis Focused Reexamination Message-ID: <[email protected]> Content-Type: text/plain; charset="us-ascii" >From what I've read, the first one, that says "sepsis focus exam completed" is >sufficient, even without the vitals above being listed. Karen Belfi, RN, MSN Quality Outcomes Coordinator Lankenau Medical Center (484)476-8092 From: Sepsisgroups [mailto:[email protected]] On Behalf Of Rutherford, Richard Sent: Friday, June 09, 2017 12:18 PM To: [email protected] Cc: Vasquez, Ashley Subject: [EXTERNAL] [Sepsis Groups] Sepsis Focused Reexamination This message originated from outside MLHS systems. Any attachments or links should be carefully considered before proceeding. Please contact the Help Desk at 484-596-4357 with any questions or forward a questionable email to [email protected]<mailto:[email protected]> ________________________________ 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. -------------- next part -------------- An HTML attachment was scrubbed... URL: <https://na01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.sepsisgroups.org%2Fpipermail%2Fsepsisgroups-sepsisgroups.org%2Fattachments%2F20170613%2F0d4a2a38%2Fattachment-0001.htm&data=02%7C01%7Cmarie.pierce1%40mclaren.org%7C418e26dabc654ed0f2ed08d4b261c316%7C82021bda879141b4807aff5b548750e6%7C0%7C0%7C636329580336311866&sdata=P19gxaJmT%2FATd%2F6Uhtq3QQsplRMzZog4IGiRuXYANfY%3D&reserved=0> ------------------------------ Message: 3 Date: Tue, 13 Jun 2017 05:33:01 -0500 (CDT) From: Carol Groen <[email protected]> To: <[email protected]> Subject: [Sepsis Groups] Sepsis Transfers Message-ID: <[email protected]> Content-Type: text/plain; charset="us-ascii" This question is for those facilities that receive transfers. When getting a severe sepsis or septic shock patient from an outside facility . . . do you repeat the labs included in the sepsis bundle? Carol Groen, MSN, RN, CEN, NE-BC| Manager Clinical Certifications & Special Projects HaysMed, part of The University of Kansas Health System 785-623-6569 (Fax: 785-623-6559)| <mailto:[email protected]> [email protected] | PO BOX 8100, Hays, Kansas 67601 Core Purpose: To help people be healthy Core Values: respect, compassion, spirituality, trustworthiness, excellence, professionalism Core Vision: To be the best tertiary care center in rural America -------------------------------------------------------------------------------------------------------------------------------------------- Important: This e-mail and any attachments may contain confidential information subject to protection under the Federal Standards for Privacy of Individually Identifiable Health Information (45 C.F.R. Parts 160 and 164). If you or your organization is a "Covered Entity" under the above mentioned regulations, you are obligated to treat such information in a manner consistent with the regulations. If it appears that this email was sent to you in error, (1) you are prohibited from utilizing or disseminating this email or any attachments; (2) please immediately delete it from your computer and any servers or other locations where it might be stored and email ([email protected]) or call Christy Stahl at 785-623-2188 advising that you have done so. We appreciate your cooperation. -------------- next part -------------- An HTML attachment was scrubbed... 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Unauthorized use, disclosure, forwarding or copying is strictly prohibited and may be unlawful. If you have received this communication in error, please notify me IMMEDIATELY at the phone number or pager listed above." _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
