In your original email- you did not present what time infection was identified. If the infection was identified at 1950 within the body of note- that would make the clinical presentation and documentation of severe sepsis/septic shock the same.
Pamela Crabtree RN CPHQ|Quality Improvement Manager Cooper University Health Care Cooper Camden Business Office/ Operational Excellence Dept. 1 Federal Street/ Suite SE2-217C. Camden, NJ 08103-1162|(office) 856.382.6635 [email protected]<mailto:[email protected]> KNOW Sepsis: Inside & Out [cid:[email protected]] CONFIDENTIAL PATIENT SAFETY WORK PRODUCT: Protected under the Patient Safety & Quality Improvement Act. Do not disclose unless authorized by Cooper University Health Care Dept. of Pt Safety. This message and any attachment is confidential, and peer review protected by Cooper University Hospital's Department of Performance Improvement. Unauthorized disclosure is absolutely prohibited. The content of this e-mail message is intended only for the personal and confidential use of the recipient(s) named above. If the reader is not the intended recipient, you are hereby notified that you have received it in error and that any review, dissemination, distribution, copying or disclosure of this message is strictly prohibited. If you have received this message in error, please advise the sender by reply e-mail, and delete it. Thank you. From: Sepsisgroups [mailto:[email protected]] On Behalf Of Schrecengost, Lisa M. Sent: Tuesday, June 26, 2018 2:49 PM To: Cox, Debra M. (RN); [email protected] Subject: Re: [Sepsis Groups] severe sepsis presentation [External] This email did not originate from within Cooper. Please STOP and THINK before opening attachments, clicking on links, or providing any information. In the body of the physician's note, he says pneumonia (no time). We have a time of sepsis dx as 19:50 in the body. At the D/C impression, he has primary impression as Pneumonia & Additional Impression as severe sepsis... (no times) Our struggle is to find out if we can use the times within the body of the note to meet our severe sepsis criteria, or do we have to take the time the note was opened since he has a dc impression of severe sepsis. I have asked quality net and it goes in circles. I thought we used the time the note was opened only if we did not have any times within the body of the note. For example, I have times for SIRS, the sepsis dx time, and lactate level of 2.9. I thought the time would be 19:50 when all criteria meets, since we have times in the documentation. My coworker says since the dr has severe sepsis as an impression, we have to use time note was opened for severe sepsis presentation time. From: Cox, Debra M. (RN) [mailto:[email protected]] Sent: Tuesday, June 26, 2018 2:19 PM To: Schrecengost, Lisa M.; [email protected] Subject: Re: [Sepsis Groups] severe sepsis presentation [External] Be aware: [This message came from outside of Spartanburg Regional Network] 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? Get Outlook for iOS<https://aka.ms/o0ukef> ________________________________ From: Sepsisgroups <[email protected]<mailto:[email protected]>> on behalf of Schrecengost, Lisa M. <[email protected]<mailto:[email protected]>> Sent: Tuesday, June 26, 2018 10:00:26 AM To: [email protected]<mailto:[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]<mailto:[email protected]> Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. **************************************************************** This communication, including attachments, may contain information that is confidential. It constitutes non-public information intended to be conveyed only to the designated recipient(s). 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