No systemic picture, no source, no sepsis surveillance, no IV/response detail.
The evolving-sepsis or recovery model note in §3/§4: the systemic picture and trend, the source and its management, the IV antibiotic/fluids, and the reason skilled surveillance was required.
“Confused today.”
In an at-risk resident, new confusion may be the first sign of sepsis — no screen.
“New confusion with a fever, tachycardia, and tachypnea and a urinary source — sepsis pathway initiated; cultures/fluids/empiric antibiotics per order; close monitoring.”
“UTI, antibiotics started.”
No systemic assessment or sepsis surveillance.
Document the systemic picture and sepsis surveillance alongside the source and its treatment.
