Form 57.119 Denominators or Outpatient Dialysis

The National Healthcare Safety Network (NHSN)

57.119_DenomOutpatDialysis_BLANK.ppt

57.119 Denominators for Outpatient Dialysis

OMB: 0920-0666

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  1. Record the number of chronic hemodialysis patients who received hemodialysis at your center on the first two working days of the month.  Count each patient only once. If a patient has both an implanted access (graft or fistula) and a catheter, count this patient as having the catheter.

  1.  Facility ID# :

  1. *Location code:

  1. *Month:

  1. *Year:

  1. *Vascular Access Type

  1. *Number of Chronic
    Hemodialysis Patients

  1. Fistula

 

  1. Graft

 

  1. Tunneled central line

 

  1. Nontunneled central line

 

  1. Other access device (e.g., hybrid access)

 

  1. *Total patients
    (sum of all patients listed above)

 

  1. Optional fields:

    Label

  1. __________

  1. __________

  1. __________

  1. __________

  1. __________

  1. Data

  1. __________

  1. __________

  1. __________

  1. __________

  1. __________

 
File Typeapplication/vnd.ms-powerpoint
File TitleSlide 1
AuthorCDC
Last Modified Byano3
File Modified2010-08-23
File Created2004-07-27
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