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


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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" <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>



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