Documentation Tip of the Week: Sepsis

Posted on Wed, Apr 08, 2015
Documentation Tip of the Week: Sepsis

Sepsis: More than Just the SIRS Criteria

Diagnostic Criteria for Sepsis Infection, documented or suspected, and some of the following:

General variables

  • Fever (> 38.3°C)
  • Hypothermia (core temperature < 36°C) 
  • Heart rate > 90/min–1 or more than two sd above the normal value for age
  • Tachypnea
  • Altered mental status
  • Significant edema or positive fluid balance (> 20mL/kg over 24hr)
  • Hyperglycemia (plasma glucose > 140mg/dL or 7.7 mmol/L) in the absence of diabetes

Inflammatory variables
  • Leukocytosis (WBC count > 12,000 μL–1)
  • Leukopenia (WBC count < 4000 μL–1)
  • Normal WBC count with greater than 10% immature forms
  • Plasma C-reactive protein more than two sd above the normal value
  • Plasma procalcitonin more than two sd above the normal value

Hemodynamic variables
  • Arterial hypotension (SBP < 90mm Hg, MAP < 70mm Hg or an SBP decrease > 40mm Hg in adults or less than two sd below normal for age)

Organ dysfunction variables
  • Arterial hypoxemia (Pao2/Fio2 < 300)
  • Acute oliguria (urine output < 0.5mL/kg/ hr for at least 2 hrs despite adequate fluid resuscitation)
  • Creatinine increase > 0.5mg/dL or 44.2 μmol/L
  • Coagulation abnormalities (INR > 1.5 or aPTT > 60 s)
  •  Ileus (absent bowel sounds) 
  • Thrombocytopenia (platelet count <100,000 µ-1)
  •  Hyperbilirubinemia (plasma total bilirubin > 4mg/dL or 70 μmol/L)

Tissue perfusion variables
  • Hyperlactatemia (> 1 mmol/L)
  • Decreased capillary refill or mottling

Possible/Probable Diagnoses
  • “Possible,” “probable,” “likely” or “suspected” diagnoses can be coded when documented by the provider in the inpatient record
  • Remember to carry this through consistently to the discharge summary
  • If the possible/probable diagnosis can be ruled out or confirmed as present then clarify this in the record
  • If the diagnosis remains uncertain, the provider can document “possible” all the way through to the discharge summary * For example: “Acute blood loss anemia due to a probable UGIB…” “Will add Zosyn for suspected gram negative pneumonia”

Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at

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