Sepsis

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Sepsis

Progression

  • When did disease process start
  • Initial versus subsequent visit

Location

  • N/A

Acuity

  • N/A

Name

  • Specify causal agent or presence of underlying systemic infection, if known-bacterial, fungal, candida
  • Examples:
    • Sepsis due to MRSA pneumonia or MRSA pneumonia with sepsis
    • Sepsis due to a post procedural infection
    • In unknown agent or source, document "sepsis, unknown source"

Necessary Procedures

  • If a diagnosis of sepsis infection following a procedure, provide the cause and effect relationship between the procedure and the postprocedural sepsis or clarify if not related to sepsis
  • Specify if present on admission

Other

  • Do not use the term urosepsis for sepsis
  • Specify septic shock if appropriate with clinical indicators such as hypotension and pressors
  • Specify any associated organ dysfunction-acute kidney failure, acute respiratory failure, encephalopathy, hepatic failure

Why

  • Localized infection, systemic, postprocedural, noninfective process-associated
  • Any known causes or underlying conditions-link the causal organism, if known or suspected