Thursday Jun 08, 2023

The impact of sepsis diagnosis and documentation, Part 1

For decades, clinicians have known that effective intervention in sepsis cases relies universally on early diagnosis. Yet, despite this fact, sepsis remains a tough challenge.  One in three patients dying in the hospital will have sepsis. Even more importantly for documentation, 87 percent of patients in the hospital with sepsis had it before admission. This episode examines ways to improve both diagnosis and documentation for sepsis patients in order to improve care and reduce the ill effects on clinicians and hospitals.


Tomas Villanueva, DO, MBA, FACPE, SFHM

Senior Principal

Clinical Operations and Quality



Linda Wiseman, BSN, RN, CCDS

Senior Consulting Director

Clinical Documentation Improvement


Show Notes:

[01:16] Differing criteria

[01:48] Need to document early

[02:38] Two classifications

[03:10] SOFA/Sepsis-3

[03:36] SIRS criteria

[04:53] SOFA criteria

[06:13] What to document on admission

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