HELP
Good morning! I feel like we have "sepsis" diagnosis coming out of our ears! Many times the patients don't look systemically ill, and we are not treating as such! Help! Docs are documenting SIRS and SEPSIS and we are only treating the localized infection. An example is PNA where we are only giving R&Z and there may only be one or two indicators such as Tachypnea or Leukocytosis-both of which we know we see with PNA. These are often also short stays, and they don't look that ill. Suggestions? We have created posters, educated, done weekly newsletters, but as we all know doctors can use any criteria they want and often when we query for what indicators used, etc. they document sepsis due to hypotension and leukocytosis.
On the other hand, we see patients with all 4 SIRS indicators and documented PNA, but we are only treating the localized infection again with R&Z. To query or not to query? If we see they are only treating localized infection?
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
[Description: CCDS_pin_1inch]
On the other hand, we see patients with all 4 SIRS indicators and documented PNA, but we are only treating the localized infection again with R&Z. To query or not to query? If we see they are only treating localized infection?
Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"
[Description: CCDS_pin_1inch]