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