Identifying infections for the purpose of determining severe sepsis presents a variety of challenges. Whether you are a novice with abstracting severe sepsis case or have been doing it for several months, here are some guidelines:
DO NOT USE:
- Terms on an X-ray that would have been used when abstracting an “abnormal x-ray” for a pneumonia core measure chart – such as infiltrates.
- Viral or fungal infections.
- Results of a test or procedure. There must be documented reference to an infection being present, suspected, or possible, i.e. positive urine result with leukocyte esterase does not equal infection.
- Severe Sepsis order sets as documentation of a suspected source of infection unless there is somewhere on the order set provider documentation indicating a suspected source of infection.
- A bowel perforation in itself. It cannot be used as a suspected infection or suspected source of infection without documentation indicating it is an infection or causing an infection.
- Pneumonia from physician diagnosis or a radiologist’s suspicion/ finding on an x-ray.
- “Infection source unknown.”
- Nursing documentation of a possible or suspected infection or that the patient is being treated for or was recently diagnosed with an infection.
- An antibiotic order that indicates a suspected infection.
- A positive finding of suspected infection over a negative finding of no infection.
- Documentation of a condition that is an infection or that includes the word “infection.”
- Free air in the abdomen. This is referred to as pneumoperitoneum and may be caused by a bowel perforation, which may result in an infection.
*Content is based on Specifications Manual Version 5.0b – October 2015 through June 2016 discharges.
**The article is part of the Registry Partners Quality Division Sepsis Newsletter. Follow the blog to read more articles from the Newsletter or contact us to receive a copy of the full newsletter to share with your team!