* required for saving **required for completion Facility ID:
|
Event #:
|
*Patient ID:
| Social Security #:
|
Secondary ID:
| |
Patient Name, Last: First: Middle:
|
*Gender: F M Other
| *Date of Birth:
|
Ethnicity (specify):
| Race (specify):
|
*Event Type: UTI
| *Date of Event:
|
Post-procedure UTI: Yes No
| Date of Procedure:
|
NHSN Procedure Code:
| ICD-9-CM Procedure Code:
|
*MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module □ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module
|
*Date Admitted to Facility:
| *Location:
|
Risk Factors
|
*Urinary Catheter status at time of specimen collection:
□ In place □ Removed within 48 hours prior □ Not in place nor within 48 hours prior
|
Location of Device Insertion: _____________ Date of Device Insertion: ___/___/_____
|
Event Details
|
*Specific Event: □ Symptomatic UTI (SUTI) □ Asymptomatic Bacteremic UTI (ABUTI) □ Other UTI (OUTI)
|
*Specify Criteria Used: (check all that apply) Signs & Symptoms Any Patient
□ Fever □ Urgency □ Frequency □ Dysuria □ Suprapubic tenderness □ Costovertebral angle
pain or tenderness
□ Abscess □ Pain or tenderness □ Purulent drainage or material □ Other evidence of infection found on direct exam,
during surgery, or by diagnostic tests‡
| Laboratory & Diagnostic Testing
□ 1 positive culture with ≥105CFU/ml with no
more than 2 species of microorganisms
□ Positive dipstick for leukocyte esterase or nitrite □ Pyuria □ Microorganisms seen on Gram stain of unspun
urine
□ 1 positive culture with ≥103 CFU/ml and < 105
CFU/ml with no more than 2 species of microorganisms
□ Positive culture □ Positive blood culture □ Radiographic evidence of infection
|
*Secondary Bloodstream Infection: Yes No
|
** Died: Yes No
| UTI Contributed to Death: Yes No
|
Discharge Date:
| *Pathogens Identified: Yes No *If Yes, specify on pages 2-3.
|
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 32 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.114 (Front) Rev 4, v6.4
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