Explaining Sepsis Reassessment

What the chart auditors are looking for

Under the CMS SEP‑1 six‑hour bundle, any patient who is still hypotensive after the 30 mL kg‑¹ bolus or whose initial lactate is ≥ 4 mmol L‑¹ must have a “repeat volume‑status and tissue‑perfusion assessment” completed and documented by an LIP before the 6‑hour clock runs out. If that note is missing or incomplete, the entire case fails the measure. 

Auditors often key on boiler‑plate phrases such as “Sepsis reassessment completed”—but the note must also satisfy one of the three documentation pathways below.

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1. Focused exam (the classic five‑bullet exam)

A single attestation that the LIP performed a repeat focused exam after the fluid bolus and documented all five of these items:

1. Vital signs

2. Cardiopulmonary exam

3. Capillary‑refill time

4. Peripheral‑pulses assessment

5. Skin findings

If any of the five bullets is missing, the element fails.

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2. Review of ≥ 5 of the 8 CMS‑listed parameters

Instead of a physical exam, the LIP may state that they reviewed at least five of the following eight data points:

• Vital signs

• Cardiopulmonary assessment

• Capillary‑refill

• Peripheral pulses

• Skin colour/condition

• Arterial O₂ saturation

• Urine output

• Shock index (HR/SBP)

Example text that passes:

“Sepsis reassessment completed 14:12. Reviewed VS, cardiopulmonary exam, cap‑refill < 2 s, peripheral pulses 2+, skin warm, UO 45 mL h‑¹.” 

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3. Any 2 of 4 hemodynamic tests

The LIP may instead document that they obtained or interpreted two of these:

• Central‑venous pressure (CVP)

• Central‑venous oxygen saturation (ScvO₂)

• Bedside cardiovascular ultrasound (IVC or LV filling)

• Dynamic fluid‑responsiveness test (passive‑leg‑raise or 250‑mL fluid challenge)

Example:

“Reassessment 15:05 – CVP 10 mm Hg; PLR ↑ stroke volume 16 %. No further fluid indicated.” 

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Practical documentation tips

Tip	Why it helps
Use an EHR smart phrase such as “.sepsisreassessment” that auto-populates all five bullets or prompts you to pick the 8‑parameter route.	Prevents missing elements.
Time‑stamp the note after the bolus but before 6 h.	Auditors match it to the bundle clock.
If nurses collect pulses or urine output, the LIP must explicitly state they reviewed those RN findings.	RN data alone doesn’t count.

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Bottom line:
“Sepsis reassessment completed” only meets SEP‑1 when the note shows either the five‑bullet focused exam, or review of ≥ 5 of CMS’s eight surrogate parameters, or two hemodynamic tests—documented by an LIP and time‑stamped within the 6‑hour window. Anything less will be marked non‑compliant.