Sepsis/Septicemia

Diagnosis: Sepsis / Septicemia

Applicable for MSDRGs: 870, 871, 872
MD documentation should address:

1. Presenting symptoms: pain and location; fever or hypothermia; vomiting with frequency and appearance; SNF or home health pt; outpt tx w/ meds; indwelling urinary catheter; other implanted devices
2. CXR findings: pneumonia or other resp condition that contributes to sepsis.
3. Radiologic Findings: evidence of an infectious process
4. O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure)
5. Lab Values: specify causative organism and treatment if applicable
6. Evidence of SIRS: Must have at least 2 of the following:
   • Tachycardia: Pulse>90
   • Tachypnea: RR >20
   • Temp >100.4 (38C) or <96.8 (36C)
   • WBC >12,000 or <4,000 or >10% bands
7. Relationship of infection to specific organ dysfunction or failure (i.e. pneumonia, UTI, RF, etc)
8. Relationship of infection to implanted device or procedure
9. **AVOID saying UROSEPSIS. Document UTI or Sepsis.**
10. Evidence of dehydration and cause if known
11. Evidence of encephalopathy and cause if known (metabolic, specific organ dysfunction)
12. Treatment with medications, procedures or therapies

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