Good afternoon everyone, We are having a difficult time getting the appropriate documentation to meet the bundle compliance even though everything is done correctly! Use of our Sepsis Screening and Evaluation Documentation tool is hit and missed although I can see by the labs and treatment protocol that they are doing it. On the IP side it is the issue with getting them to document to the Sepsis Shift Screen and Focus reassessment. With the physicians if they are here when patient is admitted to the floor they usually do an admit note that includes a focused reassessment so we will catch those. If it is after hours we are hoping to hold the ER physicians accountable to documenting a focused reassessment prior to moving patient to PCU or ICU. I would be open to suggestions for better documentation compliance also. Pam Pam
From: Sepsisgroups [mailto:sepsisgroups-boun...@lists.sepsisgroups.org] On Behalf Of Duane, Molly Sent: Thursday, April 05, 2018 11:18 AM To: Sepsisgroups@lists.sepsisgroups.org Subject: [Sepsis Groups] Question re: documentation of attestation that focused exam was completed 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. 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.
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