Sepsis Protocol Compliance Checklist
Document whether sepsis protocol steps were completed for a patient encounter and note any delays, exceptions, or follow-up actions.
Encounter Details
Medical Record / Chart ID
*
Date of Encounter
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of First Recognition of Possible Sepsis
*
Hour Minutes
AM
PM
AM/PM Option
Location / Unit
*
Clinician / Staff Name
*
First Name
Middle Name
Last Name
Clinician / Staff Role
*
Please Select
Physician
Nurse
Physician Assistant
Nurse Practitioner
Respiratory Therapist
Pharmacist
Other
Screening and Recognition
Suspected sepsis indication
*
Fever
Hypothermia
Tachycardia
Hypotension
Altered mental status
Elevated respiratory rate
Elevated lactate
Other
Onset time of concerning signs/symptoms
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Escalation criteria met?
*
Yes
No
Clinical notes
Protocol Compliance Checklist
Sepsis screen performed
*
Completed
Not completed
Provider notified
*
Yes
No
Time of notification
Hour Minutes
AM
PM
AM/PM Option
Blood cultures obtained before antibiotics
*
Yes
No
Lactate ordered
*
Yes
No
IV access established
*
Yes
No
Fluids initiated when indicated
Yes
No
Not indicated
Antibiotics ordered
*
Yes
No
Antibiotics administered
*
Yes
No
Protocol timing and completion status
Rows
Actual time recorded
Met protocol target
Time of notification
1
Blood cultures before antibiotics
2
Lactate ordered
3
IV access established
4
Fluids initiated when indicated
5
Antibiotics ordered
6
Antibiotics administered
7
Repeat lactate planned or completed
8
Reassessment documented
9
Clinical Measurements and Actions
Temperature (°C)
*
Heart Rate (bpm)
*
Blood Pressure - Systolic (mmHg)
*
Respiratory Rate (breaths/min)
*
Oxygen Saturation (%)
*
Lactate Value (mmol/L)
*
Was oxygen provided?
*
Yes
No
Not applicable
Were IV fluids given?
*
Yes
No
Not applicable
Were vasopressors considered or started if indicated?
*
Yes, considered
Yes, started
No
Not applicable
Was urine output or other monitoring initiated?
*
Yes
No
Barriers, Exceptions, and Follow-up
Reason for missed or delayed step
Order delay
Access issue
Patient refusal
Clinical instability
Transfer in progress
Test unavailable
Other
Other reason, specify
Escalation status
Please Select
No escalation needed
Escalated to provider
Escalated to charge nurse
Escalated to rapid response team
Escalated to receiving facility
Pending escalation
Other
Handoff status
Please Select
Completed
In progress
Pending
Not applicable
Pending items / follow-up actions
Submit Checklist
Should be Empty: