Sepsis vs SIRS

Unknown
edited May 2016 in CDI Talk Archive
I am having difficulty coming up with wording to query a internist on
the following.

He documented:

1.Segmental nephritis bilateral with E-Coli bacteremia

2. E.Coli induced SIRS.

I need to query him if he meant the pt had sepsis, but not quite sure
how to go about this question.

Thanks,

Patti

Patti Stewart BSN,RN
Clinical Documentation Specialist
Mercy Medical Center
1301 15th Ave. West
Williston, ND 58801
pattistewart@catholichealth.net

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    Here is a copy of my query form. It may be of some help.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov


    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens
  • michele.goossenmichele.goossen
    edited May 2016
    SIRS 2nd to an infection codes to sepsis.

    Michele Goossen, RN, BSN, CHCQM
    Clinical Documentation Specialist
    Lakeland Regional Medical Center
    863-687-1369
  • david.smithdavid.smith
    edited May 2016
    I think you have enough there to support the SIRS due to infectious
    process (sepsis) from the E.coli nephritis. If you are uncomfortable
    with the documentation as it stands, then perhaps a multiple choice list
    may get you what you are looking for. Maybe you could use the query as
    an educational opportunity on bacteremia v. sepsis/septicemia in terms
    of the difference in reporting/code assignment.
  • Unknown
    edited May 2016
    Thanks Robert, that looks great.

    Patti
  • Unknown
    edited May 2016
    Can we take that as sepsis even thought the MD did not document sepsis?
  • robert.hodges2robert.hodges2
    edited May 2016
    Anytime J

    Robert

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens
  • michele.goossenmichele.goossen
    edited May 2016
    In ICD-9 these are the only possible codes for SIRS.
    SIRS 995.90 ( Unspecified)
    SIRS due to infectious process 995.91 (Sepsis) & SIRS due to infectious process w/acute organ dysfunction 995.2 (server sepsis) SIRS due to infectious process code first the underlying infection
    SIRS due to non-infectious process 995.93 & SIRS due to non-infectious process w/acute organ dysfunction.
    & SIRS due to non-infectious process code first the underlying condition. 
  • david.smithdavid.smith
    edited May 2016
    Yes, that is how I am looking at it also. If the SIRS is clearly
    documented as due to an infectious organism then I think the only
    accurate way to report it is with the SIRS due to infectious process.
    This will take you to sepsis with SIRS. It doesn't seem correct to
    choose SIRS, unspecified in this case since the documentation includes
    "E.coli induced SIRS" in the setting of nephritis and bacteremia. I
    don't think you can have SIRS in the setting of an infection without it
    being "sepsis". Here is a definition from emedicine " Sepsis is the
    systemic response to infection and is defined as the presence of SIRS in
    addition to a documented or presumed infection."
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