Recently cases with documentation of severe sepsis/septic shock “present on arrival”; “present on admission” have been generating questions on the correct way to abstract presentation time. Consider these scenarios:
- Patient arrives to the emergency room on 12/9/15 at 1503. The clinical indicators for severe sepsis are found with the last piece suggesting a presentation date/time of 12/9/15 at 1647. In the H&P the physician documents “Patient arrived to the ED with Severe Sepsis. In this case, you would use triage time for severe sepsis presentation date and time.
- Patient arrives on 3/26/16 at 1230. Clinical indicators for Severe Sepsis were found on 3/26/16 at 1245. On 3/27/16 at 1122 the provider documents “… is admitted with Septic Shock”. The admission order was entered on 3/26/16 at 1255. This case would abstract as follows:
- Severe Sepsis presentation date/time: 3/26/16 at 1245.
- Septic Shock presentation date/time: 3/26/16 at 1255 (the time of admission).
- If the admission time had been 1240, then the presentation date/time for severe sepsis and septic shock would be 1240.