Clinical Documentation Improvement: Focus on Sepsis

The terms “bacteremia” and “sepsis” are often used interchangeably by healthcare providers. However, these should not be considered synonymous terms.
The CDC has defined five stages of illness along a continuum: bacteremia, septicemia, sepsis, severe sepsis and septic shock.

• “Bacteremia” is simply an abnormal lab finding in an otherwise asymptomatic patient.
• “Sepsis” is a systemic inflammatory response to infection with or without positive blood cultures. Common manifestations of sepsis include AMS/confusion, fever, hypoxemia, leukocytosis, bandemia, tachycardia and tachypnea.

If your patient is truly septic, please clearly state this in your progress notes, and also include the causative organism if known. Remember that “urosepsis” is a nonspecific term that is interpreted to be a simple UTI. If your patient is septic, secondary to a UTI, please state as such.

Finally, it is important that the record clearly indicates whether sepsis was present or evolving upon admission, or if it developed later in the hospital stay. It is important to distinguish between all of these diagnoses so that your patient’s severity of illness and risk of mortality are accurately reflected in the medical record.

Thank you to all of our Medical Staff for your support. Every answered Clinical Documentation Specialist query is a step toward continued improvements in patient care.

Questions? Please call HIM at your respective facility.

WellStar Cobb Hospital: 770-732-3933
WellStar Kennestone Hospital: 770-793-5294 or 770-793-5307