Sepsis/Septic Shock Management Note

Note Title: Sepsis / Septic Shock Management Note

Date/Time: [Date and time of note entry]

Author/Service: [Name, role, and service/team]

Location: [ED / ICU / ward]

Trigger: [suspected sepsis / septic shock / post-bolus reassessment / escalation to vasopressors / other]

Clinical Summary

[3–5 sentence snapshot capturing: patient context and relevant comorbidities; sepsis concern and current severity; key objective anchors (MAP, lactate with trend, mental status, oxygen requirement); current antimicrobial status; and immediate priorities for the next few hours.] (Write as a handoff-ready summary.)

Sepsis Recognition & Time Anchors

Sepsis Recognition Time: [Exact time when treating team identified sepsis / Unknown—reason]

Time Zero: [Exact time per institutional definition / Not applicable—reason]

Initial Lactate: [Time collected — value mmol/L / Pending—order time / Not done—reason]

Repeat Lactate: [Time collected — value mmol/L / Pending—order time / Not indicated—reason]

Diagnostic Criteria: [Suspected / Confirmed] infection with [key evidence]; organ dysfunction: [brief description]; Shock: [Yes—vasopressor requirement and lactate despite fluids / No]

Source Evaluation & Diagnostics

Primary Suspected Source: [Source with supporting clinical findings]

Alternative Considerations: [Brief differential / None]

Pathogen Risk Factors: [Recent hospitalization, devices, immunosuppression, prior MDROs, or None identified] (Include only if relevant.)

Cultures: [Sites, collection times, pre/post antibiotic timing, and status]

Imaging/Diagnostics: [Studies ordered or completed with key findings and status]

Source Control: [Required / Not indicated / Deferred] — [Plan and timing if required; rationale if deferred]

Treatment

Antimicrobials: [Agent(s), dose/route, start time, rationale tied to source and resistance risks, planned reassessment timing] (If delayed or not given, state reason. If cultures not obtained before antibiotics, document why.)

Fluids: [Type, total volume mL and mL/kg, start–end times, response observed] (Balanced crystalloid preferred. If limited or withheld, state reason.)

Vasopressors: [Agent, current dose, start time, route, MAP target] (If peripheral: note monitoring and relocation plan. Include Not applicable if no vasopressors.)

Corticosteroids: [Indication, agent, dose / Not indicated]

Reassessment

Time of Reassessment: [Exact time]

Interventions Since Last: [Brief summary of fluids, antibiotics, pressor titrations, procedures]

Perfusion Response:

• MAP/BP and pressor trend: [Values and trajectory]
• Mental status: [Normal / Altered with description]
• Skin/capillary refill: [Warm/cool, mottling, cap refill time]
• Urine output: [mL over interval and mL/kg/hr]
• Lactate change: [Latest value and trend / Pending—order time]

New Concerns/Complications: [Pulmonary edema / Arrhythmia / Extravasation / None / Other]

Next Actions: [Planned interventions, monitoring, and escalation criteria for next 1–3 hours]

(Use "Pending—[details]" for tests ordered but not resulted. Use "Not done—[reason]" when a recommended element was omitted. Time-critical elements in Sepsis Recognition & Time Anchors should always be documented with explicit status. Do not state "adequately resuscitated" without supporting exam findings and objective measures.)