Unless the provider states "severe sepsis" or "Septic shock", the case would be excluded for no sign of organ dysfunction. I agree, and wish they would add acute mentation change as a sign of organ dysfunction, but to date, they have not. If you are within the 30 days post discharge window, you might ask a provider (if they agree) to add that specific wording mentioned above.
I disagree that documentation in the discharge summary cannot be used: we have been burned more than once by providers stating in the discharge summary, "septic shock present on admission" - when providers at admission were not following that diagnosis. EXAMPLE: AMI, stroke, or GI bleed present on admit, also patient aspirated and develops pneumonia. Just because they aspirated around time of admission does not mean they had septic shock POA- low BP could be because of the other diagnoses. Thank you, Betsy Ask your patients and staff: What matters to YOU? -----Original Message----- From: Sepsisgroups <[email protected]> On Behalf Of [email protected] Sent: Tuesday, February 9, 2021 1:04 PM To: [email protected] Subject: Sepsisgroups Digest, Vol 358, Issue 1 *** Warning: This email originated from outside of Overlake Hospital Medical Center. Do not click links or open attachments unless you recognize the sender and are expecting the message. Report suspicious emails to Overlake Helpdesk at x5278 *** Send Sepsisgroups mailing list submissions to [email protected] To subscribe or unsubscribe via the World Wide Web, visit http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org or, via email, send a message with subject or body 'help' to [email protected] You can reach the person managing the list at [email protected] When replying, please edit your Subject line so it is more specific than "Re: Contents of Sepsisgroups digest..." Today's Topics: 1. I need some clarification and would appreciate some input (Cooke, Susan) ---------------------------------------------------------------------- Message: 1 Date: Wed, 3 Feb 2021 16:40:52 +0000 From: "Cooke, Susan" <[email protected]> To: "[email protected]" <[email protected]> Subject: [Sepsis Groups] I need some clarification and would appreciate some input Message-ID: <sa2pr10mb45219f63ccb42b19df349ea68a...@sa2pr10mb4521.namprd10.prod.outlook.com> Content-Type: text/plain; charset="us-ascii" Hi everybody, I am going round and round with our Abstracting company related to a UTI sepsis case. Patient came to ED meeting SIRS criteria and a change in mental status which was reported as definitely improved after antibiotic administration. The Bundle elements were met. The coding was for Sepsis and UTI with a primary of Altered Mental Status. All were POA. The Abstractors excluded the case because they say the patient did have evidence of organ dysfunction because CMS does not recognize Altered Mental Status as Organ dysfunction (but SCCM does). 1. Is this correct that the case should be excluded even though the patient clearly had sepsis. Improved with antibiotics and it was coded as such by the physician? 2. In my email to the Abstractor I had mentioned (because I'm somewhat new to this level of detail and didn't realize the altered mental status wasn't an organ dysfunction) that it was clearly stated in the Discharge Summary that the patient had Altered Mental Status that improved with Antibiotics and the source was a UTI. I was told that -Also,any documentation in the discharge summary is not to be used to determine the presence of severe sepsis/septic shock. Is this true? Isn't the entire chart a possible source for a sepsis diagnosis? Any insight to this type of scenario would be so helpful!! Thanks so much. Sue Susan Cooke MSN RN NEA-BC Sepsis Program Coordinator University Medical Center New Orleans 2000 Canal Street New Orleans, LA 70112 O 504.702.2924 F 504.702.2119 [email protected]@LCMChealth.org<mailto:[email protected]@LCMChealth.org> umcno.org<https://www.umcno.org/> -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.sepsisgroups.org/pipermail/sepsisgroups-sepsisgroups.org/attachments/20210203/655e7ea8/attachment-0001.html> ------------------------------ Subject: Digest Footer _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org ------------------------------ End of Sepsisgroups Digest, Vol 358, Issue 1 ******************************************** DISCLAIMER: This message is confidential, intended only for the named recipient(s) and may contain information that is privileged or exempt from disclosure under applicable law. If you are not the intended recipient(s), you are notified that the dissemination, distribution or copying of this information is strictly prohibited. If you received this message in error, please notify the sender then delete this message. _______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
