TY Sepsis Education Session

Froggy Jumps

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Documentation pearls for the TY group

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Amanda Hansell

United States

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TY Sepsis Education Session


Froggy Jumps TY Sepsis Education SessionOnline version Documentation pearls for the TY group by Amanda Hansell 1 Your patient is in septic shock, but has a history of heart failure (ejection fraction 20%) or ESRD. What should you do about fluid resuscitation? a Avoid giving fluids due to these comorbidities. b Give the recommended 30 mL/kg bolus. c Assess the patient's volume status clinically before deciding on the fluid bolus volume. 2 What criteria for giving less than 30 ml/kg fluid bolus is missing from this documentation? a The new target volume b The reason for giving less than 30 mL/kg c Nothing is missing: Both the reason and the new target volume are documented 3 If you adjust the amount of fluids for a patient with severe heart failure or end-stage renal disease, what documentation is most important? a There is no special documentation. It is most important to consider these comorbidities. b Clearly document your reasoning, including the condition, for adjusting the fluid bolus volume. c Document your reasoning and identify a new, tailored target fluid bolus volume for the patient. 4 If you initially listed multiple possible sources of sepsis (UTI vs PNA vs pressure ulcer for instance), and you confirm the source is from the pressure ulcer, how should this be documented? a Update your progress note to reflect the confirmed source and remove the other possibilities. b Leave the note and use the discharge summary to clarify that sepsis was due to a pressure ulcer. c Continue listing all the initial possible sources every day, even though you know the source. 5 Your patient presents with elevated troponin levels. EKG and echo without changes. No c/o chest pain. How do you label this finding? a Type 1 myocardial infarction. b Type 2 myocardial infarction. c Non-ischemic myocardial injury. 6 You requested an ABG, but received a VBG instead. How do you adjust the pH value to approximate an ABG reading? a Add 0.04 to the venous pH b Subtract 0.04 from the venous pH c Ask ChatGPT for help interpreting the blood gas values 7 How do you choose antibiotic coverage for a patient with an infected stage 4 sacral pressure ulcer? a Review the wound culture result. b Choose broad coverage until the result of the bone culture is available. c All infected wounds should be treated with cefepime and vancomycin. 8 Is the severity of sepsis documented correctly in this note? HR: 105, RR: 28, WBC: 17, BP: 88/54 a Yes, this patient has sepsis. b No, this patient has sepsis with associated organ dysfunction. c No, this patient has septic shock. 9 The sepsis reassessment should be completed: a On all sepsis patients. b After the fluid bolus to determine the fluid status of the patient, and if vasopressors are needed. c To determine if a fluid bolus is needed. 10 Patient admitted with: sepsis due to infected stage 4 sacral wound. Is this documentation adequate to fully explain the source of sepsis? a No, because "wound" is non-specific, the term pressure ulcer should be used b Yes, this is a stage 4 sacral wound. c The sepsis source is not important.

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TY Sepsis Education Session

Froggy Jumps

About this activity

Created by

Download the paper version to play

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TY Sepsis Education SessionOnline version

by Amanda Hansell

Your patient is in septic shock, but has a history of heart failure (ejection fraction 20%) or ESRD. What should you do about fluid resuscitation?

What criteria for giving less than 30 ml/kg fluid bolus is missing from this documentation?

If you adjust the amount of fluids for a patient with severe heart failure or end-stage renal disease, what documentation is most important?

If you initially listed multiple possible sources of sepsis (UTI vs PNA vs pressure ulcer for instance), and you confirm the source is from the pressure ulcer, how should this be documented?

Your patient presents with elevated troponin levels. EKG and echo without changes. No c/o chest pain. How do you label this finding?

You requested an ABG, but received a VBG instead. How do you adjust the pH value to approximate an ABG reading?

How do you choose antibiotic coverage for a patient with an infected stage 4 sacral pressure ulcer?

Is the severity of sepsis documented correctly in this note? HR: 105, RR: 28, WBC: 17, BP: 88/54

The sepsis reassessment should be completed:

Patient admitted with: sepsis due to infected stage 4 sacral wound. Is this documentation adequate to fully explain the source of sepsis?