Sepsis Evaluation/Bundle Note

Sepsis Evaluation/Bundle Note

Patient: [name, identifiers per local policy]

Location: [ED / ICU / ward]

Date/Time: [note date and time]

Author: [name and role]

Key Times

(Use explicit date and time for all entries; verify and do not copy-forward.)

Recognition/concern time: [date/time sepsis first suspected]

Time zero: [date/time and institutional trigger criteria] (Include only if institution tracks)

Septic shock recognized: [date/time] (Include only if applicable)

Outside hospital times: [antibiotics/fluids/cultures with timestamps from transferring facility] (Include only if transfer)

Clinical Presentation

[Reason sepsis evaluation initiated] (One sentence stating the trigger: screening positive, clinician concern, abnormal vitals, or lab alert.)

[Focused HPI] (4–8 sentences: onset and trajectory; infectious symptoms by system; pertinent comorbidities and risk factors including immunosuppression, indwelling devices, recent procedures, dialysis access; recent antibiotics or hospitalization; medication/allergy constraints relevant to antimicrobial selection.)

[Suspected source(s) of infection with supporting findings; whether urgent source control is needed; planned intervention and consultations if applicable]

[Diagnostic uncertainty statement] (Include only if infection is unconfirmed: leading diagnosis, key alternatives including noninfectious mimics, rapid reassessment plan, and criteria for narrowing or discontinuing antibiotics.)

Organ Dysfunction Summary

• Hemodynamics: [SBP/MAP; hypotension yes/no; vasopressor requirement] (Specify acute change vs baseline)
• Perfusion: [lactate value with time drawn; capillary refill; skin perfusion]
• Renal: [creatinine; urine output over defined interval] (State if acute vs chronic)
• Respiratory: [oxygen requirement and modality; SpO2] (Include only if relevant)
• Neuro: [mental status—baseline vs current] (Include only if relevant)
• Other: [platelets, bilirubin, coags] (Include only if relevant)

[Severity statement: criteria for sepsis vs septic shock met, tied to documented findings; if uncertain, state uncertainty and monitoring plan]

Interventions

(Chronological order with explicit timestamps. If a bundle element was not obtained, document "Not obtained/Not performed" with rationale.)

Cultures: [date/time; site(s); number of sets; peripheral vs line draws] — Obtained before antibiotics: [yes / no]; if no: [rationale]

Lactate: [date/time; result; interpretation and repeat plan if elevated] — If not obtained: [rationale]

Antibiotics: [For each agent: drug, dose, route, start date/time, indication/target organisms, de-escalation plan with triggers and timeframe; note renal/hepatic adjustments and allergy considerations if applicable]

Fluids: [type; total volume; start/end times; weight used for mL/kg] — If deviating from standard resuscitation: [patient-specific rationale and alternative strategy]

Vasopressors: [agent; start time; route/line type; current dose; MAP goal] (Include only if initiated)

Respiratory support: [modality; key settings; escalation steps] (Include only if required)

Source control: [planned procedure; consult times; anticipated timing; barriers] (Include only if indicated)

Reassessment

Reassessment time: [date/time] (Document after fluids or vasopressor initiation)

• Repeat focused exam: [vital signs with MAP; cardiopulmonary exam; capillary refill/skin perfusion; mental status; urine output trend]
• Dynamic/objective measures: [bedside ultrasound findings; passive leg raise response; CVP/ScvO2 or other indices] (Include if used)
• Repeat lactate: [date/time; result; trend] — If indicated but not obtained: [rationale]
• Response summary: [improved / stable / worsened] — [one to three supporting data points]

Assessment & Plan

Assessment: [Working diagnosis: suspected sepsis due to source with organ dysfunction manifesting as findings; key alternatives if diagnostic uncertainty persists]

Plan:

• Infection/source: [pending diagnostics; source control steps; consultations]
• Hemodynamics: [fluid strategy; vasopressor targets]
• Respiratory: [oxygen goals; escalation triggers] (Include only if relevant)
• Monitoring: [repeat labs; lactate timing; ICU triggers; reassessment frequency]
• Antimicrobial stewardship: [reassessment window; de-escalation criteria and timeline]

Disposition: [ICU / stepdown / ward / transfer] — [rationale: vasopressor requirement, lactate trend, oxygen needs, mental status, perfusion]

Goals of care: [treatment limitations; effect on bundle decisions; participants in discussion] (Include only if limitations exist)

Handoff summary: [sepsis status—suspected/confirmed, shock yes/no; total fluids; current vasopressor/dose; last lactate; antibiotics given and next due; pending cultures/imaging; escalation triggers]