Sepsis Chatter – Severe Sepsis, Septic Shock & Infection

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Susan VonBosse

RN Quality Consultant

Welcome to the June 2022 Edition of Sepsis Chatter!

Our newest video presentation is titled: “Severe Sepsis, Septic Shock and Infection: Abstracting the Earliest Documented Time from One Provider Note” 

This presentation begins with a review of determining when severe sepsis is present using provider documentation only and severe sepsis present met by clinical criteria. In addition, we will review the four common challenges related to determining the earliest time when severe sepsis, septic shock, or infection is documented in one provider note:

  • Abstracting the earliest time when it is directly attached to severe sepsis, septic shock, or infection within one provider note.
  • Abstracting the earliest time when multiple times are directly associated with documented severe sepsis, septic shock, or infection in one provider note
  • Abstracting the earliest time when no time is directly associated with documented severe sepsis, septic shock, or infection in one provider note
  • Abstracting the earliest time when more than one instance of severe sepsis, septic shock or infection is documented with and without times attached in one provider note

Each of the covered topics will include specific abstraction guidance that is defined in the current/ upcoming CMS Specifications Manual for National Hospital Inpatient Quality Measures. We will review the application of these guidelines using examples and rationale.

*This presentation is based on the information included in the most current version of the Specifications Manual for National Hospital Inpatient Quality Measures version 5.11 (Discharges January 1 through June 30 2022 (2Q22)) and the upcoming version 5.12 (Discharges July 1 through December 31, 2022) *For the most accurate guidance, please refer to the version of the Specifications Manual that corresponds to the Discharge Date(s) that are being reviewed.