Documentation of Sepsis, Severe Sepsis and Septic Shock

Posted on Feb 6, 2018 in Announcements | 0 comments

There continue to be missed and mis-diagnoses as well as CDI and coding queries about sepsis –much of this reflects unfamiliarity with the definitions and clinical indicators for sepsis, severe sepsis and septic shock.  For these reasons, it seems like a good time to review this information.  The following examples and comments are based on the current ICD-10 and CMS coding guidelines (which reflect Sepsis-1 and Sepsis-2 definitions).  The Sepsis-3 definitions were initially published in early 2016, but haven’t been adopted by ICD-10 and CMS yet.

Your patient could have SEPSIS if she is ill from a suspected or confirmed infection and has 2 or more SIRS criteria.  If there’s no infection, there’s no sepsis.  And if there’s infection but no SIRS criteria, there’s no sepsis.

The SIRS criteria are:

Temp > 38 C/100.4 F

            < 36 C/ 96.8 F

  HR > 90/min

  RR > 20/min

  WBC > 12k or < 4k or 10% bands

+ if the SIRS criteria can be explained by something else, don’t use them to determine if the patient has sepsis.

++ if the patient has SIRS but no infection, this is non-infectious SIRS (document the cause)

+++ Lactic acidosis is NOT a SIRS criteria

EXAMPLE of IDEAL DOCUMENTATION: “sepsis from UTI (SIRS criteria WBC 15k and temp 101”).

Avoid the term “urosepsis”

ANOTHER EXAMPLE: “non-infectious SIRS due to severe pancreatitis, no sepsis”


SEVERE SEPSIS is currently defined as SEPSIS with acute organ dysfunction that is DUE TO or SECONDARY TO SEPSIS.

A few examples of organ dysfunction:

acute respiratory failure, hypoxic and/or hypercarbic

acute renal failure, AKI, ATN

acute encephalopathy

Lactic acidosis > 2 but less than 4  (AVOID the terms “elevated lactic acid or “elevated lactate”) 


Hepatic failure, shock liver

DIC, thrombocytopenia

AMI, acute coronary synd


MODS multiple organ dysfunction syndrome

+ if the organ dysfunction is due to sepsis, document this association

++ if the lactic acidosis is due to sepsis, document this association

IDEAL DOCUMENTATION: “Severe sepsis from empyema, with DIC due to sepsis”

ANOTHER EXAMPLE: “Severe sepsis—leg cellulitis with SIRS and lactic acidosis due to sepsis”

ANOTHER EXAMPLE: “Severe sepsis—aspiration pneumonia with acute encephalopathy due to sepsis”


If after iv fluid, the patient with SEVERE SEPSIS still has SBP < 90 mmHg or 40 mmHg below baseline and

MAP < 65 OR has persistent lactic acidosis > 4, then document SEPTIC SHOCK.

+ if present, specify other etiologies of shock as well

Beth Gong, MD for the CDI Team /— contact me if questions

Drug shortages

Posted on Jan 10, 2018 in Announcements | 0 comments

American College of Surgeons Honors Alta Bates Summit Medical Center for Quality Surgical Care

Posted on Nov 6, 2017 in Announcements | 0 comments

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) has recognized Alta Bates Summit Medical Center – Summit Campus as one of 66 ACS NSQIP participating hospitals that have achieved meritorious outcomes for surgical patient care.  As a participant in ACS NSQIP, Alta Bates Summit Medical Center – Summit Campus is required to track the outcomes of inpatient and outpatient surgical procedures and collect data that directs patient safety and the quality of surgical care improvements. Read More

Sutter Community Connect

Posted on Nov 6, 2017 in Announcements | 0 comments

CVSP-IR Holiday Schedule

Posted on Nov 6, 2017 in Announcements | 0 comments

We (CVSP/IR) will be closed Thursday, November 23rd and Friday, November 24th. We will have call team available.

To contact the IR MD on call –can be reached at 925-975-3161, for above dates.

Any questions let me know.


Carolina Correa RN
Summit CVSP Charge Nurse
(510) 655-4000 office ext. 4922
(510) 869-8037 cisco phone

ABSMC Follow-Up Appointment and Post Discharge Call Program

Posted on Oct 10, 2017 in Announcements | 0 comments

Alta Bates Summit Follow-Up Appointment and Post Discharge Call Program

We are pleased to announce that on September 20th (Summit) and 27th (Alta Bates) we implemented our follow-up appointment and post discharge call program. We have partnered with Sutter Physician Services (SPS) to provide the following to our inpatient discharges to home that are 18 years and older:

  • Schedule follow-up appointment(s) with PCP and other treating physicians prior to the patient’s discharge.
  • A phone call by an SPS nurse within the first 24-48 hours post discharge to address patients’ needs and care activities.
  • If an issue is identified, the nurse will follow-up with the physician and/or escalate the issue back to the Medical Center.
  • Physicians will receive documentation of the outreach encounter in their Sutter EHR in basket or via fax.

Physicians can help make this program a success!

  • Document the Anticipated Date of Discharge in your notes.
  • Communicate to Case Management if you identify an error in the PCP so they can correct it.
  • Recognize that “Follow-Up Provider” is where SPS looks for the Provider to make the appointment with and reads notes under instructions for that Provider.
  • Recognize that the Demographics section is where the patient phone number is identified.

You are a valued partner and we welcome your participation and feedback.  Please contact Dr. Ursi Boynton ( or Leslie Costa ( for any questions or issues.

Leslie Costa, RN, PhD, CWON
Director Clinical Program Support
Alta Bates Summit Medical Center
Phone: 510-869-6144
Fax: 510-869-6956