The following sample query was donated to ACDIS by Advisory Board member Paul Evans, RHIA, CCS, CCS-P, CCDS, manager, Regional Clinical Documentation at Sutter West Bay in San Francisco. Contact him at evanspx@sutterhealth.org.
Documentation and coding of severe sepsis matters in terms of patient risk assessment and establishing sepsis as a diagnosis, as well as the effect of such documentation (and subsequent code assignment) on quality measures.