Hello all.....
Need help!! We are having issues with figuring out severe sepsis presentation times. We are having discrepancies at our facility understanding what times to use, especially when the physician has severe sepsis as the impression and there are other times within the note. We have a patient that comes into the ED. The note was opened at 16:37 by the physician. In the body of the report, it says "Time of sepsis diagnosis is 19:50". Pulse of 104 at 16:19. Respirations of 24 at 16:19. Lactate 2.9 at 17:50. He documents in the body of the note "the patient has severe sepsis but not septic shock". Primary impression documented on the ED Physician Report is Pneumonia, additional impression is Severe Sepsis. What time should we collect as Time of Severe Sepsis? Do we take the time the note was opened since he has an impression of severe sepsis or use the times within the body of the note? Thanks for your time, Lisa Lisa Schrecengost RN BSN Quality Management ACMH Hospital One Nolte Drive Kittanning, PA 16201 Phone: 724-543-8871 email: schrecengo...@acmh.org Confidentiality Notice: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
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