• Jamie Arberry, Zanya Henry, and Tumena Corrah.
• Northwick Park Hospital, London, UK.
• Clin Med (Lond). 2021 May 1; 21 (3): 222225222-225.

IntroductionSepsis 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.MethodsWe 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.ResultsBeforehand, 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.DiscussionDespite requiring ongoing education and encouragement of clinicians and coders, implementation of the template was quick, cheap and easy and improved sepsis coding.© Royal College of Physicians 2021. All rights reserved.

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