Sepsis Screening Checklist
Complete this checklist to support clinical sepsis screening and triage. Please fill out all sections based on current patient status.
Patient or Encounter ID
*
Screening Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Screening Location/Department
*
Please Select
Emergency Department
Intensive Care Unit
Medical Ward
Surgical Ward
Outpatient Clinic
Other
Signs or Symptoms Suggestive of Sepsis (select all that apply)
*
Fever or hypothermia
Tachycardia (increased heart rate)
Tachypnea (increased respiratory rate)
Altered mental status
Hypotension (low blood pressure)
Suspected or known infection
Other
Temperature (°C)
*
Heart Rate (beats per minute)
*
Respiratory Rate (breaths per minute)
*
Systolic Blood Pressure (mmHg)
*
Any Risk Factors or Pre-existing Conditions?
Immunosuppression
Recent surgery or invasive procedure
Chronic illness (e.g., diabetes, renal failure)
None known
Other
Screening Outcome / Next Step
*
Sepsis suspected – escalate care immediately
Monitor and reassess
No sepsis suspected
Submit Screening
Should be Empty: