TY - JOUR T1 - A simple measure to improve sepsis documentation and coding JF - Clinical Medicine JO - Clin Med SP - 222 LP - 225 DO - 10.7861/clinmed.2020-0868 VL - 21 IS - 3 AU - Jamie Arberry AU - Zanya Henry AU - Tumena Corrah Y1 - 2021/05/01 UR - http://www.rcpjournals.org/content/21/3/222.abstract N2 - 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. ER -