A simple measure to improve sepsis documentation and coding

摘要

INTRODUCTION:Sepsis incidence and mortality are increasing, yet sepsis appears to be under-recognised and under-reported. Accurate recognition and coding of sepsis allows for appropriate funding and accurate epidemiological representation.METHODS:We implemented a discharge summary template for all patients discharged from our infectious diseases service and analysed sepsis documentation and coding before and after its introduction.RESULTS:Beforehand, we found that 59% of 29 patients had sepsis, yet only 10% had it documented on their discharge summary, and 17% had it coded. Following implementation of the template, 38% of 52 patients had sepsis documented, yet only 20% of these had it coded. After delivery of a training session to the coders regarding the importance of sepsis, 38% of patients with a diagnosis of sepsis had it coded.DISCUSSION:Despite requiring ongoing education and encouragement of clinicians and coders, implementation of the template was quick, cheap and easy and improved sepsis coding.? Royal College of Physicians 2021. All rights reserved.