Documentation Tip: Sepsis-3

Posted on Mon, Apr 11, 2016
Documentation Tip: Sepsis-3

Our recurring feature of documentation tips for clinicians.

By Timothy Brundage, MD

New sepsis criteria has been announced by the Society of Critical Care Medicine, as published in JAMA.

Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.

  • Organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%.

Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone.
  • Vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater AND
  • Serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

Bedside Quick SOFA (qSOFA):  at least 2 of the following clinical criteria:
  1. Respiratory rate of 22/min or greater
  2. Altered mentation
  3. Systolic blood pressure of 100 mm Hg or less.

Timothy Brundage

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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