Documentation of adult sepsis

Part of the January 2019 Quest newsletter

With the implementation of ICD-10, there is an increased need to document specific details related to many diagnoses. It’s important to remember that bacteremia, sepsis, severe sepsis, and septic shock are not synonymous. We’ve compiled a few helpful hints and examples to ensure accurate sepsis clinical coding.


Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction is represented by an increase in the sequential (sepsis-related) organ failure assessment (SOFA) score (see table below) of 2 or more points. When baseline values are unknown, they should be assumed to be normal.

Septic shock: A subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Patients can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure ≥ 65 mmHg and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.

  • Despite adequate fluid resuscitation,
    • Vasopressors required to maintain MAP > 65 mmHg and
    • Serum lactate level > 2mmol/L

qSOFA (quick SOFA): A simplified version of SOFA. Any two of the following criteria identifies patients at risk for poor outcomes.

  • Hypotension (SBP < 100 mmHg)
  • Respiratory rate (>22 breaths per minute)
  • Alteration in mental status

Related diagnoses

Bacteremia: The presence of viable bacteria in the blood

Systemic inflammatory response syndrome (SIRS): The body’s systemic response to infection or non-infectious causes

  • Temperature >38 or <36 degrees C
  • Heart rate >90/min
  • Respiratory rate >20/min or PaCO2 <32mmHg
  • WBC >12k or <4k or >10% bands

ICD-10-CM coding and documentation needs

  • Sepsis: Document sepsis and include the criteria met to arrive at the diagnosis and the infection type, if known. Include how the condition is being monitored, evaluated, and/or treated. In most circumstances an underlying infection can be confirmed, but it is not unusual to see cases of sepsis where a localized infection is not identified especially in immunocompromised patients or those on chemotherapy. Include clear documentation regarding whether the condition was present on admission (POA).
  • Septic shock: Document septic shock and include documentation of clinical indicators such as hypotension, despite fluids and treatment, noting how the condition is being monitored, evaluated, and/or treated.
    • Hypotension despite fluids and treatment is not synonymous with septic shock; the two terms are not interchangeable, and each have unique ICD-10-CM codes. 


Here are three examples of documentation of sepsis that would need to be updated according to the guidelines. Coding compliance:

Example #1

Sepsis documentation which states: “Concern for sepsis.” This documentation would need clarification:

Patient admitted thru emergency room with the diagnosis of “Due to concern for sepsis,” from unknown source, broad spectrum antibiotics started.” Vital signs: Temperature 38.5, heart rate 120, blood pressure 166/78, pulse oxygenation 92%

  • Laboratory values stated: Leukocytosis 12.9 up from 8.4
  • Anemia hemoglobin 6.4 down from 7.8
  • Lactic acid 2.5

Treatment: Start IV antibiotics and IV fluids

No mention of “sepsis” in the documentation again until day 8 and note states: “Severe sepsis, skin ulcer infection. Lactic acidosis, due to sepsis.”

  • LIP wound need to clarify the diagnosis according to the day 8 documentation if clinically significant. “Sepsis due to skin ulcer infection” was present on admission.
  • This diagnosis would then need to be carried through to the discharge note again for clarification and accurate documentation.

Example #2

Sepsis documentation with multiple conditions stated in progress notes that could cause sepsis. This documentation would need clarification.

Patient admitting with vitals on initial presentation: Blood pressure 157/114, temperature 38.9, heart rate 132, Sa02 99%, lactic acid was 1.2.

  • She was given 2 liters fluid bolus.
  • Dexamethasone 10 mg
  • IV Clindamycin

The progress notes then state:

  • Acute kidney injury: Could be due to infection and sepsis, NSAIDS but strep can cause glomerulonephritis

Will get urinalysis, run electrolytes, and renal ultrasound.

Start normal saline at 125 cc/hr

Monitor intake/output/daily weights

  • Thrombocytopenia most likely due to infection, sepsis

Will get repeat CBC, peripheral smear and coagulopathy studies.

  • Active Problems: tonsillitis with strep pharyngitis and Acute kidney injury

There is no statement that specifies Sepsis due to. Query was sent for clarification and MD stated:

Sepsis secondary due to Strep. Pharyngitis – start Penicillin V 500 mg TID.

Recommend outpatient evaluation for possible tonsillectomy.

Being worked up for tonsillectomy at this time.

Example #3

Sepsis documentation with no supportive documentation in progress notes

Patient admitted through emergency room

  • Vital signs: Temperature 36.5, blood pressure 114/72, Sa02-99%, heart rate 110
  • Progress notes state: Likely sepsis due to small bowel obstruction
  • Sepsis never mentioned again
  • Patient did not meet sepsis criteria on admission, so clarification query would be sent.


Pinson, R.D., & Tang, C.L. (2018). Reproduced from 2018 CDI Pocket Guide. © 2017 HCPro, TN., 35 Village Road, Suite 200, Middleton, MA 01949, 800-650-6787. Used with permission.

Singer, e. a. (2016, February 23). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Journal of the Americal Medical Association, 801-810. doi:doi:10.1001/jama.2016.0287.

Contact and more information

Please contact the Clinical Documentation Improvement Department with any questions. Further education regarding this topic is available for your team through the CDI department.