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Is there anything in the ED record or nursing documentation showing a source? 
This can even be "Sepsis ED order" or the triage impression of a code Sepsis. 
If so, what time is this documentation?

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________________________________
From: Sepsisgroups <[email protected]> on behalf of 
Schrecengost, Lisa M. <[email protected]>
Sent: Tuesday, June 26, 2018 10:00:26 AM
To: [email protected]
Subject: [Sepsis Groups] severe sepsis presentation [External]

Be aware: [This message came from outside of Spartanburg Regional Network]

Hello all…..


Need help!!   We are having issues with figuring out severe sepsis presentation 
times.   We are having discrepancies at our facility understanding what times 
to use, especially when the physician has severe sepsis as the impression and 
there are other times within the note.


We have a patient that comes into the ED.  The note was opened at 16:37 by the 
physician. In the body of the report, it says "Time of sepsis diagnosis is 
19:50". Pulse of 104 at 16:19. Respirations of 24 at 16:19. Lactate 2.9 at 
17:50. He documents in the body of the note “the patient has severe sepsis but 
not septic shock”.
Primary impression documented on the ED Physician Report is Pneumonia, 
additional impression is Severe Sepsis. What time should we collect as Time of 
Severe Sepsis?   Do we take the time the note was opened since he has an 
impression of severe sepsis or use the times within the body of the note?


Thanks for your time,
Lisa




Lisa Schrecengost RN BSN
Quality Management
ACMH Hospital
One Nolte Drive
Kittanning, PA 16201
Phone:  724-543-8871
email:  [email protected]
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