Required Provider Documentation for the New CMS Sepsis ...
[Pages:7]Required Provider Documentation for the New CMS Sepsis Core Measure
Nicky Huntley, MS, ACCNS-AG, RN Med/Surg CNS
Sepsis Coordinator UPDATED: 11/5/2015
SERVICE AREA (Edit this in the Master Slide Area)
Significance and Relevance
? October 1st 2015: Sepsis Management is a CMA Core Measure ? Reimbursement related to documentation
? UCHealth has Sepsis Coordinators. ? Goals are formal system collaboration to improved sepsis mortality outcomes. ? Metro Denver Sepsis Coordinator is Nicole Huntley, MS, ACCNS-AG, RN. ? Abstractions for this new Core Measure beginning October, 2015. ? nicole.huntley@ ? Office: 720-848-6649
SERVICE AREA (Edit this in the Master Slide Area)
Sepsis "Time Zero" per CMS
ED ? ED*: Time Zero is noted as the
time of triage
*Patients admitted from Out Side Hospital (OSH) are not included in
our CMS reporting*
Inpatient
? Time Zero is noted as the time of provider documentation of Severe Sepsis and/or Septic Shock
OR
? If it is noted "suspect infection from ___", then within 6 hours documentation must include:
? 2 or more SIRS criteria AND
? Evidence of organ dysfunction
SERVICE AREA (Edit this in the Master Slide Area)
After documentation of Time Zero the Clock starts!
? Severe Sepsis: Three Hour and Six Hour Counters ? Septic Shock: Three Hour and Six Hour Counters
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TABLE ONE: Repeat Volume Status and Tissue Perfusion Assessment must consist
of EITHER:
? A focused exam including:
? Any two of the following four:
? Vital signs, AND ? Cardiopulmonary exam,
AND ? Capillary refill evaluation,
AND ? Peripheral pulse
evaluation, AND ? Skin examination
OR:
? Central venous pressure measurement
? Central venous oxygen measurement
? Bedside Cardiovascular Ultrasound
? Passive Leg Raise or Fluid Challenge
Charting Requirements for each element are on the SERVICE AREA (Efdoit tlhlios iwn thine MgasstelriSdliede Area)
Documented Repeat Physical Exam Requirements:
Document this exam OR 2 of the 4 elements on the next slide
SERVICE AREA (Edit this in the Master Slide Area)
*TWO of the these 4 clinical elements must be documented within 6 hours of severe sepsis or septic shock presentation*
? Measure CVP
? Perform Bedside CV Ultrasound
? Cannot be from a PICC or midline
? Measure SvO2 or Scvo2
? Perform Passive Leg Raise
SERVICE AREA (Edit this in the Master Slide Area)
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