Documentation and Coding for Patient Safety Indicators
Sep 15, 2000 · (Severe sepsis can only be coded if there is documentation to support a relationship between the severe sepsis and the acute organ dysfunction.) (UHC Documentation Guide, Sepsis_SIRS). If the medical record uses the term urosepsis and meets the clinical indicators for sepsis, query the M.D. to determine if urosepsis means a simple urinary tract ... ................
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