If you are using an EHR, build in a smart phrase that includes the elements and pulls them from the documentation. As we move toward E-measures, it will require less free text and more structured documentation.
It is much easier to actually do the documentation then to figure out ways to get around it. Lori J. Muhr DNP, MHSM/MHA, APRN-Rx, ACNS-BC, CCRN, CEN, LSSBB Manager Sepsis and DSRIP Clinical Integration Projects 817-702-1717 -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of [email protected] Sent: Wednesday, June 14, 2017 2:17 PM To: [email protected] Subject: Sepsisgroups Digest, Vol 250, Issue 5 Send Sepsisgroups mailing list submissions to [email protected] To subscribe or unsubscribe via the World Wide Web, visit http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org 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. Re: Sepsis Focused Reexamination (Murray, Sandra) ---------------------------------------------------------------------- Message: 1 Date: Tue, 13 Jun 2017 13:44:33 +0000 From: "Murray, Sandra" <[email protected]> To: "Belfi, Karen" <[email protected]>, "Rutherford, Richard" <[email protected]>, "[email protected]" <[email protected]> Cc: "Vasquez, Ashley" <[email protected]> Subject: Re: [Sepsis Groups] Sepsis Focused Reexamination Message-ID: <bn6pr02mb336134c040f8b34841fbff17c2...@bn6pr02mb3361.namprd02.prod.outlook.com> Content-Type: text/plain; charset="us-ascii" That is my understanding, too. Thank you, Sandy Murray Sandy Murray, RN, BSN | Heart Failure & Sepsis Program Coordinator Performance Improvement-Patient Safety and Risk T 817.848.4963 | M 682.367.3032 [email protected]<mailto:[email protected]> Follow us on Social Media Follow us on Social Media [THHEB - email.png] Follow us on Social Media From: Sepsisgroups [mailto:[email protected]] On Behalf Of Belfi, Karen Sent: Tuesday, June 13, 2017 6:40 AM To: Rutherford, Richard <[email protected]>; [email protected] Cc: Vasquez, Ashley <[email protected]> Subject: Re: [Sepsis Groups] Sepsis Focused Reexamination [EXTERNAL] >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]<mailto:[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. The information contained in this message and any attachments is intended only for the use of the individual or entity to which it is addressed, and may contain information that is PRIVILEGED, CONFIDENTIAL, and exempt from disclosure under applicable law. If you are not the intended recipient, you are prohibited from copying, distributing, or using the information. 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