* Required for saving
| ** Required for completion
| | |
Facility ID#:______________
| Event #: ___________
| | | |
*Patient ID#: ______________
| Social Security #:___________________
| | |
Secondary ID#: ___________
| | | | | | |
Patient Name:
| Last:_______________
| First:___________
| Middle: _____________
|
*Gender:
| ____F
| ____M
| | *Date of Birth:
| ___/___/_____
| | |
Ethnicity (specify):
| ______________
| Race (specify): _____________
| | |
*MDRO Type:_____________
| *Outpatient ___Y ___N
| |
*Event Date:
| ___/___/_____
| *Specimen Source:
| ____________________
|
*Date Admitted to Facility:
| ___/___/_____
| *Location: _______________
|
*Evidence of previous LIME at your facility for MDRO category in the 3 months before Admission Date?
| ____Y
| ____N
|
**Date of most recent LIME:
| ___/___/_____
| |
*Has patient been discharged from your facility in the past 3 months?
| ____Y
| ____N
| |
**Date of most recent discharge from your facility:
| ___/___/_____
| | | |
Custom Fields
| | | | | | |
Label
| Label
|
_______________________
| ___/___/____
| ________________________
| ___/___/_____
|
_______________________
| ___________
| ________________________
| ____________
|
_______________________
| ___________
| ________________________
| ____________
|
_______________________
| ___________
| ________________________
| ____________
|
_______________________
| ___________
| ________________________
| ____________
|
_______________________
| ___________
| ________________________
| ____________
|
_______________________
| ___________
| ________________________
| ____________
|
Comments
| | | |
| |
