Molly, We had the same issue with physicians documenting everything that occurred for hours within the note they started at the time of admission. We requested for the physicians to add a date and time of their re-assessments. This has surprisingly worked for us since we were able to show failures due to the technicalities.
Linda G. Pender RRT-NPS Sepsis Coordinator Patient Care Services Administration Navicent Health phone: 478-633-6806 pager: 4444 KNOW Sepsis: Inside & Out Confidential Quality Improvement: Not for Disclosure Email: pender.li...@navicenthealth.org -----Original Message----- From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of sepsisgroups-requ...@lists.sepsisgroups.org Sent: Thursday, April 05, 2018 4:07 PM To: email@example.com Subject: Sepsisgroups Digest, Vol 284, Issue 3 [ W A R N I N G ] This email originated outside of Navicent Health. Do not click on links or attachments unless you recognize the sender and know the content is safe. 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Question re: documentation of attestation that focused exam was completed (Duane, Molly) ---------------------------------------------------------------------- Message: 1 Date: Thu, 5 Apr 2018 12:17:56 -0400 From: "Duane, Molly" <mdu...@dmc.org> To: "Sepsisgroups@lists.sepsisgroups.org" <Sepsisgroups@lists.sepsisgroups.org> Subject: [Sepsis Groups] Question re: documentation of attestation that focused exam was completed Message-ID: <DC544FE7FA833F49A1F4F0CA3CDC145003BDC7001F59@MAIL03.dmcnt1.local> Content-Type: text/plain; charset="us-ascii" Hello All, I was wondering if your physicians were using the attestation statement instead of documenting the specific focused exam components. If so, how is that going? How did you implement this? We had a miss this month: even though the physician documented in his note the specific amount of fluid that was given, followed with "after these interventions the patient was reassessed", we missed because the attestation did not have a specific time included. The time the note was opened/started was used. This was an ED note, started at the beginning of the pt's visit, so that was prior to fluids being given. It is frustrating to see that the correct care is being given, yet we are missing on documentation technicalities. Does anyone have suggestions? Thanks, Molly Molly Duane RN, BSN, CCRN Sepsis Program Coordinator Detroit Receiving Hospital Harper-Hutzel Hospital Mobile: 248-709-6218 DRH: 313-966-8087 HUH: 313-745-4340 Email: mdu...@dmc.org<mailto:mdu...@dmc.org> This message (including any attachments) is confidential and intended solely for the use of the individual or entity to whom it is addressed, and is protected by law. 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