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Case Identification and Sepsis Trigger

Encounter and patient identifiers match audit record critical (required)

Documented time of sepsis recognition or SEP-1 clock start critical (required)

Note (optional)

Evidence of suspected infection plus organ dysfunction documented critical (required)

Yes No N/A

Source documentation supports sepsis screening trigger

Yes No N/A

3-Hour Bundle Elements

Blood cultures obtained before antibiotics critical (required)

Yes No N/A

Blood culture collection timestamp documented critical (required)

Note (optional)

Serum lactate obtained within 3 hours of sepsis recognition critical (required)

Yes No N/A

Initial lactate result documented critical (required)

Note (optional)

Broad-spectrum antibiotics administered within 3 hours critical (required)

Yes No N/A

Antibiotic administration timestamp documented critical (required)

Note (optional)

6-Hour Bundle Elements

Crystalloid fluid resuscitation given for hypotension or lactate ≥ 4 mmol/L when indicated critical (required)

Yes No N/A

Fluid volume administered documented critical (required)

Note (optional)

Repeat lactate obtained when initial lactate was elevated critical (required)

Yes No N/A

Repeat lactate timestamp documented

Note (optional)

Vasopressors initiated if hypotension persisted after fluids

Yes No N/A

Hemodynamic reassessment documented within 6 hours critical (required)

Yes No N/A

Documentation and Timeframe Validation

All required timestamps are present and internally consistent critical (required)

Yes No N/A

Antibiotic, culture, lactate, and fluid documentation can be linked to the same encounter critical (required)

Yes No N/A

Provider note documents clinical rationale for sepsis management decisions

Yes No N/A

Missing or conflicting documentation identified

Note (optional)

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Run: Sepsis Bundle SEP-1 Compliance Audit

Case Identification and Sepsis Trigger

3-Hour Bundle Elements

6-Hour Bundle Elements

Documentation and Timeframe Validation

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