* required for saving Facility ID:_______________________
|
*Month/Year:______ /______
|
No NHSN Patient Safety Modules Followed this Month
|
Device-Associated Module
|
Locations ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________
| CLA BSI
| DE
| VAP
| CAUTI
| CLIP
|
Procedure-Associated Module
|
Procedures
___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________
| SSI (Circle one setting) In Out Both In Out Both In Out Both In Out Both In Out Both In Out Both In Out Both In Out Both In Out Both In Out Both
| Post-procedure PNEU (Circle) In In In In In In In In In In
|
Medication-Associated Module: Antimicrobial Use and Resistance
|
Locations ___________________ ___________________ ___________________ ___________________ ___________________
| Antimicrobial Use
| Antimicrobial Resistance
|