Sepsis Medical Record Review: Pilot Study
This report provides the findings and lessons learned from the pilot study for a national retrospective medical record review examining clinical records of patients with sepsis and suspected sepsis in Australia.
The Commission conducted a pilot study for a national retrospective medical record review to assess the clinical documentation of sepsis patients across hospital and pre-hospital settings.
The pilot study examined three questions:
- To what extent are cases of sepsis recognised (by the hospital coder and clinical treating team)?
- Are there cases of gold standard sepsis management?
- What factors influence deviation from local sepsis guidelines and pathways?
Due to the limited sample size associated with the pilot study, the analysis provided in the report is mostly descriptive in nature. However, the report informs future studies in relation to the recognition and management of sepsis in acute health care settings.
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