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

From: Sepsisgroups [] On 
Behalf Of Duane, Molly
Sent: Thursday, April 05, 2018 11:18 AM
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?

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

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