Sepsis Screening Protocol Checklist
Comprehensive sepsis screening protocol for early recognition and treatment including SIRS criteria assessment and sepsis bundle implementation.
- Industry: Healthcare
- Frequency: Per screening/Ongoing
- Estimated Time: 10-15 minutes
- Role: Nurse/Physician
- Total Items: 32
- Compliance: Surviving Sepsis Campaign, CMS SEP-1 Measure, Joint Commission Standards
Infection Suspected
Infection assessment
- Infection suspected or documented?
- Suspected source identified?
SIRS Criteria
Systemic inflammatory response
- Temperature >38°C or <36°C?
- Heart rate >90?
- Respiratory rate >20 or PaCO2 <32?
- WBC >12K or <4K or >10% bands?
Organ Dysfunction
End-organ damage
- Hypotension (SBP <90 or MAP <65)?
- Lactate elevated?
- Acute mental status change?
- Urine output <0.5 mL/kg/hr?
Sepsis Bundle (if positive screen)
3-hour bundle
- Lactate level measured?
- Blood cultures obtained before antibiotics?
- Broad-spectrum antibiotics given within 3 hours?
- 30 mL/kg crystalloid for hypotension/lactate ≥4?
Pre-Assessment Information
Initial assessment documentation and patient/facility identification
- Assessor Name / Credentials
- Assessment Date
- Department / Unit
- Assessment Type (Routine/Annual/Complaint)
- Previous assessment findings reviewed?
Infection Prevention & Control
Verify infection control practices per CDC and Joint Commission standards
- Hand hygiene compliance observed?
- Appropriate PPE available and properly used?
- Isolation precautions properly implemented?
- Sharps containers available and not overfilled?
- High-touch surfaces properly disinfected?
Patient Safety & Identification
Verify patient safety protocols and identification procedures
- Two patient identifiers used before procedures?
- Fall risk assessment completed?
- Call light within patient reach?
- Bed in lowest position with brakes locked?
Medication Safety & Management
Verify medication handling and administration practices
- Medications stored securely and at proper temperature?
- Controlled substances properly secured and counted?
- No expired medications in stock?
- High-alert medications properly labeled?
Related Healthcare Checklists
- Medical Record Audit Checklist
- Clinical Equipment Inspection Checklist
- Hand Hygiene Compliance
- Medication Safety Check
- Medication Storage Unit Inspection Checklist
- Nursing Competency Verification Checklist
- Dental Office Sterilization and Infection Control Checklist
- Nursing Home Fall Prevention Assessment Checklist
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Why Use This Sepsis Screening Protocol Checklist?
This sepsis screening protocol checklist helps healthcare teams maintain compliance and operational excellence. Designed for nurse/physician professionals, this checklist covers 32 critical inspection points across 8 sections. Recommended frequency: per screening/ongoing.
Ensures compliance with Surviving Sepsis Campaign, CMS SEP-1 Measure, Joint Commission Standards. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the Sepsis Screening Protocol Checklist cover?
This checklist covers 32 inspection items across 8 sections: Infection Suspected, SIRS Criteria, Organ Dysfunction, Sepsis Bundle (if positive screen), Pre-Assessment Information, Infection Prevention & Control, Patient Safety & Identification, Medication Safety & Management. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed per screening/ongoing. Each completion takes approximately 10-15 minutes.
Who should use this Sepsis Screening Protocol Checklist?
This checklist is designed for Nurse/Physician professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.