SIRS

katysuegood@gmail.com

I am trying to solidify our documentation regarding SIRS/Sepsis in anticipation of I-10. We have always had a joint query for SIRS/Sepsis but I want to have a separate one for us to use when we suspect SIRS (mainly to avoid inaccurate capture of Sepsis). I am wondering if you think it is appropriate to only have the options of:
 SIRS (Systemic Inflammatory Response Syndrome)
 No systemic response
 Other:
 Unable to Determine

I am struggling to come up with any other appropriate answers. The new Query Brief does suggest that there may be circumstances where only one option is appropriate. Is this one, or what am I missing?

Also, the designation of with/without organ failure is significant in I-10 (CC vs MCC), is it appropriate to ask if there is associated organ failure?

I have attached a draft.

Thanks for your help!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

sbeatty

Katy,

I think this looks fine. I think we need to query for non-infectious SIRS to accurately reflect severity and risk. I-10 will make this more important as you noted.

lprescott

Katy, we have a template for SIRS which offers the choice SIRS due to infection, SIRS due to trauma...this works quite well.
Laurie L. Prescott RN, MSN, CCDS, CDIP
lprescott@morehead.org

katysuegood@gmail.com

Yes. Unfortunately, when we use our SIRS/SEPSIS query to attempt to capture SIRS, we often get the response of 'sepsis' even though we have provided extensive education on the difference. Hence why I want a separate query.

Thanks for your feedback!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

rmhosler1

Katy:

I think this is a great idea. I struggle with the same. The problem for me has been that the first question in the grouper after SIRS is typed in is 1. due to infectious process 2. due to non infectious process.

It sounds like you are using SIRS and SEPSIS on the same sheet. How about having SIRS only and the above choices in addition to other and unable to determine?

My worry is with your wording as above, you won't get through grouper.




Mary A. Hosler RN, MSN CDS
Mary A Hosler, RN, MSN CDS
Alumnus CCRN
McLaren Bay Region
1900 Columbus Ave.
Bay City, Michigan 48708
(989) 891-8072
mary.hosler@mclaren.org

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

katysuegood@gmail.com

Good point Mary, on the query I have attached, I included the question of the underlying cause of the SIRS. Hopefully the provider answers this (in our system the queries are electronic and we set required fields that they must answer to sign off). My only question is what happens if the cause is not clear (to the MD)? My understanding is that this is only an issue in I-9. I believe that in I-10 SIRS will only refer to noninfectious sources. You will no longer be able to have SIRS 2/2 infection. The index only gives noninfectious as an option. I don’t know how this will play out with the encoder though. I am developing this query to address issues in I-10 (though clearly we still have a lot of time where we will be addressing I-9) and want to make sure It is formulated with that in mind.
I think that currently, my best bet is to try to get the MD’s to identify a potential source as often as possible?
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404