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: [email protected] -----Original Message----- From: Sepsisgroups [mailto:[email protected]] On Behalf Of [email protected] Sent: Thursday, April 05, 2018 4:07 PM To: [email protected] 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. Sender: [email protected] ========================================================================================================= * ** 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. 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" <[email protected]> To: "[email protected]" <[email protected]> Subject: [Sepsis Groups] Question re: documentation of attestation that focused exam was completed Message-ID: <[email protected]> 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: [email protected]<mailto:[email protected]> 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. If you are not the intended recipient, please delete the message (including any attachments) and notify the originator that you received the message in error. Any disclosure, copying, or distribution of this message, or the taking of any action based on it, is strictly prohibited. Any views expressed in this message are those of the individual sender, except where the sender specifies and with authority, states them to be the views of Tenet Healthcare Corporation. -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20180405/d60e38e3/attachment-0001.html> ------------------------------ Subject: Digest Footer _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ------------------------------ End of Sepsisgroups Digest, Vol 284, Issue 3 ******************************************** CONFIDENTIALITY NOTICE: The information transmitted in this e-mail message, including any attachments, is for the sole use of the intended recipient(s) or entity to which it is addressed and may contain confidential, privileged, and/or proprietary information. Any unauthorized review, retransmission, use, disclosure, dissemination, or other use of, or taking any action in reliance upon this information by persons or entities other than the intended recipient is prohibited. If you are not the intended recipient, you are hereby notified that any reading, dissemination, distribution, copying, or other use of this message or its attachments is strictly prohibited. If you have received this message in error, please notify the sender immediately by reply e-mail, or by calling (478) 633-7272, and destroy the original message, attachments, and all copies thereof on all computers and in any other form. Thank you. Navicent Health. http://www.navicenthealth.org/ _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
