Sepsis/SIRS Criteria on Query

mdomineseymdominesey
edited May 2016 in CDI Talk Archive
I think that it is very important to provide physicians with accepted criteria when querying them for a condition.

I reviewed the Sepsis query forms in the forms and tools library and one has an excellent table embedded into it. Most list criteria, but one query listed there appears directive in nature.

That being said, we know that we should not title a query with the diagnosis that we expect. So, how do folks here query for Sepsis/SIRS when the criteria are present? (increased WBC, Increased Temp, Increased HR, Increased RR, presence of infection, increased lactic acid)

This is one area where we must be certain not to suggest an inappropriate diagnosis, but on the flip side, it often goes undocumented when it should be in the record (affecting SOI/ROM and Reimbursement)

Is there a best practice out there in the CDI world? Should we create one if none exist?

Thanks,

Mark



Mark N. Dominesey, RN, BSN, MBA, CCDS
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital
W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org

Comments

  • Unknown
    edited May 2016
    This is when we do a verbal query!

    Tracey
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    This is my current standard sepsis query form. If I have positive blood cultures I generally substitute "bacteremia" for "infection".

    I am sure its not perfect. I'll take feedback/suggestions as well.

    Katy
  • katysuegood@gmail.comkatysuegood@gmail.com
    In regards to criteria,
    I agree it is very helpful, we have an issue with fitting everything on one page. We do have criteria posted in dictation rooms, most of our Drs are pretty good about it.

    Katy
  • Unknown
    edited May 2016
    Add a question for present on admission

    Tracey
  • katysuegood@gmail.comkatysuegood@gmail.com
    Tracey,
    Its on there, at the bottom. Thanks though!

    Katy
  • Unknown
    edited May 2016
    Oops sorry

    Tracey
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Our queries are electronic. When I query for sepsis: I list the
    diagnosis physician has documented, any hx of fever or s/s related to
    sepsis, VS (in ER and admit that meet criteria) and lab results,
    treatment (antibiotics, blood cx, UA &cx,etc.) and then ask physician to
    document dx these findings may indicate. In the electronic query we have
    an area below our query question area for "example/reference" and that
    is where I include sepsis/SIRS, septicemia, severe sepsis definitions
    and criteria for sepsis for the patient's age (pediatrics).
    Sepsis is a work in progress here. Physicians seem to prefer :SIRS. We
    have seen improvement :)

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603
    Pager: 98-1001
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    "Request for Documentation Clarification
    Abnormal Labs/Inflammatory Response"


    (We use a form titled as above for the topic of 'bacteremia, septicemia,
    SIRS, Sepsis - none of these terms are in the title of the form, and the
    MD has the option to indicate "none, unable to determine" and so forth.


    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
  • dvitalone1dvitalone1
    edited May 2016
    We changed all our titles of our queries to "Documentation Clarification." Its just easier this way.
  • Unknown
    edited May 2016
    Sepsis is on the radar with the surviving sepsis campaign( http://www.survivingsepsis.org/Pages/default.aspx) We approached the critical care attending and he presented sepsis and the type of queries we would be asking during grand rounds. Documentation specialists completed house wide physician education on this topic. Now when we send a query they know why and what we are asking. We also title the query documentation clarification.

    Good luck

    Tracey
  • paxnerospaxneros
    edited May 2016
    Our queries are titled Documentation Prompts. We do not title them by diagnosis.

    For Sepsis our query Starts by declaring that the patient is being treated for an Infection and we indicate the infection in a blank. It then informs the physician that the following clinical indicators are also documented w/in the record and lists the clinical indicators at the top w/a blank available to each side for us to fill in w/abnormal indicators.

    Underneath in a table format it lists the following choices w/ the instructions to further clarify the underlying cause of these Systemic findings including:

    Localized Infection Only
    Sepsis (SIRS due to infection)
    Non-infectious SIRS
    Another Condition
    None
    Unable to Determine.

    This is a template from our training co.

    Thanks,
    NBrunson
  • Unknown
    edited May 2016
    The point that commenters are overlooking is communicating with the physician the "old fashioned" way, that is verbal communication. CDI is not merely about episodic chasing down of diagnoses with queries; on the contrary, CDI is intended to ultimately change physician behavior patterns of clinical documentation. Quite frankly, one does not alter patterns of clinical documentation by the physician simply by leaving a query and hoping the physician responds. There is no substitute for face -to-face communication with physicians, engaging in a 2 minute conversation to clarify diagnoses and offering tidbits on the direct impact of accurate and concise clinical documentation to their practice of medicine.

    Just some food for thought...
  • Unknown
    edited May 2016
    You are exactly right..

    Tracey
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