Documentation best practices: Non-infectious SIRS

By Julie Shayne, RN, CCDS, Intermountain Health Clinical Documentation Integrity Educator

Documenting non-infectious SIRS – with or without organ dysfunction – when clinically significant accurately supports the intensity of your service, severity of illness, risk of mortality, length of stay and risk-adjustment metrics.

SIRS can develop due to a non-infectious source, for example: pancreatitis, DKA, trauma, poisoning/overdose, cirrhosis, malignancies, bowel obstruction, perforation or ischemia, ETOH withdrawal and more.

Key documentation concepts to apply:

• Link conditions when applicable:

  • “SIRS 2/2 acute pancreatitis with acute kidney failure”

  • “SIRS 2/2 trauma with acute organ dysfunction, lactic acidosis”

  • “SIRS due to DKA without organ dysfunction”

• If SIRS is present, but documentation is unclear, a query might be placed to determine the underlying cause and association to organ dysfunction, if present.

Medical case: 6-day LOS, impact without and with SIRS with organ dysfunction

Remember, your CDI team is here to help and serve as a resource for your documentation needs to ensure an accurate clinical picture of the patient is reflected. Please email julie.shayne@imail.org with any questions.