Document the sepsis-specific skilled surveillance and management each day:
The systemic picture: temperature (fever or hypothermia), heart rate, respiratory rate, blood pressure, mentation (new confusion is an early and important sign), and the vital-sign trend against parameters.
The suspected or confirmed source and its status (urinary, respiratory, wound, line, abdominal), and the response to source control and antibiotics.
For recovery: the resolution trajectory (defervescence, normalizing vitals, improving mentation and intake), the IV antibiotic course, and the risk of recurrence and functional decline.
MDS-supportive data
Sepsis and the source infection are coded in MDS Section I, IV medication and isolation in Section O0110, antibiotics in Section N, and nutrition/hydration in Section K. The record must document the systemic surveillance, the source and its management, and the antibiotic/fluid administration so the MDS is supported.
