Septecemia vs sepsis

Unknown

I need to leave a query for a physician regarding the diagnosis of Strep. Septicemia. This patient came in with fatigue and cellulitis of the arm. The blood cultures were done on admit, and the following day they were positive and the diagnosis of Strep.Septicemia was made.

I am trying to figure out how to word the query asking him if the patient had sepsis.

Any help would be appreciated.

Thanks,
Patti

lspryszak

You didn't mention any of the clinical indicators of sepsis, so would the diagnosis be supported by the record: evidence of organ impairment (oliguria, unstable B/P, altered mental status), multiple SIRS criteria, etc.?

It sounds as though the bloodstream infection (septicemia) is appropriate, but from the scenario it doesn't look like the patient has a systemic process (sepsis).

Without the strong clinical picture of a really SICK patient, I (personally) would not even query for sepsis. From a coding standpoint "Sepsis" is actually coded as an additional diagnosis, not the PDx. The PDx would be septicemia (038.X), the cellulitis (682.3) and sepsis (995.91)"systemic inflammatory response syndrome due to infectious process without acute organ dysfunction)would be secondary conditions.

robert.hodges2

Here is my bacteremia/SIRS/Sepsis query. Hope it helps. You may also
want to document if the Lactic Acid level is elevated and ask the
clinical significance of that.



Robert



Robert S. Hodges, BSN, MSN, RN, CCDS

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

Unknown

So are we encouraging the docs to not even document septicemia?