Q&A: Pre-admission temperature readings as clinical indicators

Q: If the patient reports an elevated temperature at home, can we use that towards reporting systemic inflammatory response syndrome (SIRS) criteria or does the elevated temperature have to be taken at the hospital?

A: Things that patients do/take at home have less validity then those performed and documented in the hospital. Patients may misrepresent and/or misunderstand results from tests taken at home compared to a professional who’s actually making those measurements.

With that said, if everything that was taken at home is consistent with the patient’s presenting condition in the ED, then there is validity to that measurement from home. If not, there’s going to be lesser validity. With that said, follow the narrative. The narrative should make it clear that what was taken at home was consistent with what was taken at the hospital.

Typically, our physicians say that the patient has “subjective fevers,” which basically means that the patient said they have a fever. If they don’t have any other symptoms, I’m not sure that I would even query for sepsis. In some instances, we do include pre-hospital reports that the patient has brought with emergency services though.

Editor’s note: Shelly McBrayer, BSN, RN, CCS, CCDS, CDI coordinator at Chesapeake (Virginia) Regional Healthcare and Cesar M. Limjoco, MD, CDI physician advisor consultant, answered this question during the webinar “Sepsis: Resolving Documentation and Coding Conflicts through CDI,” originally broadcast on July 19. The session will be rebroadcast on October 18, 1-3 p.m. eastern. Click here to learn more.