A simple measure to improve sepsis documentation and coding

Abstract

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.

Keywords: coding; funding; infection; quality improvement; sepsis.

Fig 1.

The discharge summary template implemented to increase sepsis documentation and coding. Red circled areas indicate the newly introduced areas to indicate sepsis in the patient.