Sepsis Urosepsis

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Trace DC78-12

DiraChart Clinical Reference
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1. Purpose and clinical relevance

DiraChart Clinical Reference

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Smart phrases

EMR dot-phrases; replace merge fields in braces. These supplement — never duplicate — the clinical-reference and overlay smart phrases.

.SEP_SURVEIL

Sepsis surveillance ({source/risk}): T {##}, HR {##}, RR {##}, BP {##}/{##}, mentation {baseline/change}, trend {stable/deteriorating}. Source {status}. Skilled early-sepsis surveillance required. Supports Section I; goal {###}. (General/Constitutional reference.)

.SEP_EVOLVING

Evolving sepsis: T {##}, HR {##}, RR {##}, {new confusion}, source {urinary/resp/wound/line}. Sepsis pathway initiated; SBAR {time}; cultures/labs/IV fluids/empiric antibiotics per order without delay; representative notified; close monitoring; {transfer?}. Reassess {frequency}. Time-critical. Supports Section I/O.

.SEP_RECOVERY

Post-sepsis recovery day {#} on IV antibiotics: afebrile/{T}, HR/BP {normalized vs peak}, mentation {toward baseline}, intake {improving}, IV antibiotic per order via patent line, source {resolving}, no new systemic signs. Skilled recovery management + recurrence surveillance. Supports Section I/O/N. (Source reference.)

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