I have a question regarding sepsis documentation. I have been seeing
documentation in charts like this:
Impression:
1. Sirs-stage 1, 2, or 3
2. Pneumonia
3. UTI
4. IDDM
Plan:
1. Etc
2. Etc
3. Etc
My question is why is it not being written as a diagnosis such as SIRS, sepsis,
septic shock? If SIRS is present, running through the differentials can help
with locating a source as well as looking at other clinical data so where is
the staging coming from? Is SIRS now in stages because I cannot find that
information and if the vital signs, white count, and lactate show a positive
SIRS screening then the source should be identified and therefore written as
either sepsis with or without shock or septic shock, etc.
Has anyone else seen this and if so can you point me to where the information
is located because I have been trying to research this and cannot find it.
Thank you and very respectfully,
Angie Sanders, APN, MSN, ACNS-BC
Clinical Coordinator
Twin Cities Hospital
Niceville, Fl. 32578
(850) 729-9345
"Do not follow where the path may lead. Go instead
where there is no path and leave a trail." ~Anonymous
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Twin Cities Hospital has earned The Joint Commission's Gold Seal of Approval(r)
and offers the Area's FIRST Certified Orthopedic Joint Replacement Program.
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