Q&A: Documenting definitative sepsis
Q: Our physicians frequently document ‘meets sepsis criteria.’ Is this a bad habit forming? If the patient is septic, shouldn’t the physician state sepsis due to, or just sepsis? I worry that if the patient has a few vital signs off the physicians are documenting sepsis.
A: This is a great question and one that continues to come up regardless of whether your program is just starting up or in its 10th year. Although capturing appropriate sepsis documentation is often a priority for new programs, lapses in education, changes in clinical standards, and shifts in coding guidelines all call for continued diligence in capturing appropriate, accurate documentation on this topic.
In short, documenting “meets sepsis criteria” is not the same thing as documenting the diagnosis of “sepsis.” I agree with you, it’s probably a bad habit. Many providers routinely document sepsis because of the Surviving Sepsis campaign (from the Society of Critical Care Medicine) and high profile cases like the one in New York, which recently received political attention.
Consider, whether everyone who reviews the record would interpret documentation of ‘meets sepsis criteria?’ Would someone code ‘sepsis’ based on it?
If it was present on admission, then sepsis will often be the principal diagnosis (a systemic infection trumps a local infection, according to Official Guidelines for Coding and Reporting). However, CDI specialists/coders need to consider if the condition was treated, monitored, required diagnostics, increased nursing care and/or increased the length of stay, as required by the Uniform Hospital Discharge Data Set (UHDDS).
CDI specialists also need to ensure that the documented clinical indicators support treatment of either a local or systemic infection. The Surviving Sepsis campaign outlines clinical indicators to support the diagnosis of sepsis, and it offers specific treatment recommendations. Does the entirety of the medical record support an “ill appearing” or “toxic” appearing patient? Or does the H&P under general assessment reflect “no acute distress?”
The sepsis criteria are very common, but we often forget that these indicators are present in a “toxic” patient who has an initiating condition. If the initiating condition is an infection that has overwhelmed the body so that it is now affecting other body systems, then we are dealing with sepsis. If the origin is a non-infectious condition that triggers a systemic inflammatory response, like a burn, we are dealing with SIRS.
Another factor when applying these criteria is if the symptoms are sustained. A high temperature and heart rate in the ER that returns to normal after treatment with an antipyretic in a patient with an elevated white blood count probably doesn’t support the diagnosis of a septic patient.
Furthermore, coders may not code sepsis if the only documentation in the record consists of the verbiage “meets sepsis criteria.” CDI specialists can help explain the reasons for this and explain to physicians that if they definitely want sepsis coded (and are making that diagnosis) then the documentation needs to be clearer with phrases such as “evidence of sepsis” or “treating sepsis.” If the physician merely considered the diagnosis of sepsis, they may want to document something like “meets sepsis criteria, but sepsis ruled out.” You could also start querying the provider asking them to clarify if the diagnosis of “sepsis” has been confirmed or ruled out.
You could also offer general provider education regarding the diagnosis of sepsis. Some key issues to address are how does your organization define sepsis? Is there a sepsis protocol that would support the diagnosis of sepsis through consistent treatment? Is the source of the systemic inflammatory response documented to differentiate between sepsis and SIRS? Has the systemic inflammatory response led to organ failure? Has the systemic inflammatory response led to circulatory failure? Was the systemic inflammatory response present on admission? Lastly, always document when sepsis or SIRS has been ruled out.
Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, answered this question. At the time of this article's original release, she was the CDI Education Director for HCPro Inc.