Hi Everyone, Here is the answer I received on the t.bili. See below.
Sandra Murray, RN, BSN | Heart Failure & Sepsis Program Coordinator Performance Improvement-Patient Safety and Risk T 817.848.4963 | M 682.367.3032 [email protected]<mailto:[email protected]> [cid:[email protected]] Follow us on Social Media This document was generated by, or was prepared by or at the direction or request of a medical committee, medical peer review committee, nursing peer review committee, and/or patient safety committee, including a joint committee, of Texas Health Resources and its member hospitals as defined under Texas Health & Safety Code Sec. 161.031, et seq., Texas Occ. Code Secs. 151.001, et seq., 160.001, et seq. and 303.001, et seq., and is used for committee purposes, specifically, quality assurance and assessment and the evaluation of patient safety and medical and healthcare services at the Hospital. This document and the information contained within it are considered confidential, privileged and not subject to court subpoena pursuant to the above-cited statutes and 42 U.S.C. Sec. 11101, et seq. From: IQR Q&A System [mailto:[email protected]] Sent: Thursday, July 07, 2016 10:07 AM To: Murray, Sandra; [email protected] Subject: Organ dysfunction [Incident: 160707-000039] Recently you requested personal assistance from our on-line support center. Below is a summary of your request and our response. If this issue is not resolved to your satisfaction, you may reopen it within the next 1095 days. Thank you for allowing us to be of service to you. To access your question from our support site, click here.<https://urldefense.proofpoint.com/v2/url?u=https-3A__cms-2Dip.custhelp.com_app_account_questions_detail_i-5Fid_297092&d=DQMFAw&c=tAAbe3VWSXg4_eMSItYKuRlnp5vCb2OrQZQHnRXk_fc&r=YmGf8IzG_BSHAsWPCc-bClR3kFWXmHZEEr52gBMw9tY&m=wBdcLhLQuBOpjXTdeIS3NCVIRKafMUoU_BgPZScd8qI&s=kaLYlrsLnGJtgxbH-N8Ig8uN6dVtRlg59791U1MXSIU&e=> Subject Organ dysfunction Discussion Thread Response Via Email (Char Teed) 07/07/2016 11:06 AM Sandra, Considering the guidelines: If an abnormal lab value (e.g. elevated creatinine) is considered due to a chronic condition or medication, the relation should be supported within the medical record. If a relation between the abnormal lab value and a chronic condition or medication is not identified within the medical record, the abnormal lab value can be considered evidence of organ dysfunction in relation to severe sepsis. This type of documentation will most likely be physician/APN/PA but is not limited to physician/APN/PA documentation. There is no limitation on where the documentation is located, but it must be in the current medical record. Customer By Web Form (Sandra Murray) 07/07/2016 10:41 AM Would you count a t.bili of 9.3 with a patient coming in with acute cholecystitis? Question Reference #160707-000039 Product Level 1: Measures & Data Element Abstraction Category Level 1: Hospital Inpatient - Sepsis Category Level 2: Severe Sepsis Present Date Created: 07/07/2016 10:41 AM Last Updated: 07/07/2016 11:06 AM Status: Resolved (IP only) Discharge Period: 10/01/2015 - 06/30/2016 CCN: 450639 [---001:001308:64156---] The information contained in this message and any attachments is intended only for the use of the individual or entity to which it is addressed, and may contain information that is PRIVILEGED, CONFIDENTIAL, and exempt from disclosure under applicable law. If you are not the intended recipient, you are prohibited from copying, distributing, or using the information. Please contact the sender immediately by return e-mail and delete the original message from your system.
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