* required for saving Facility ID:
| ** required for completion Event #:
|
*Patient ID:
| Social Security #:
|
Secondary ID:
| |
Patient Name, Last: First: Middle:
|
*Gender: M F Other
| *Date of Birth:
|
Ethnicity (Specify):
| Race (Specify):
|
Event Details
| |
*Event Type: [For Event Type = BSI, PNEU, SSI, or UTI use the event specific form]
| *Date of Event:
|
Post Procedure Event: Yes No
| Date of Procedure:
|
MDRO/CDI Infection Surveillance: Yes
| NHSN Procedure Code:
| ICD-9-CM Procedure Code:
|
*Specific Organism Type: (Select up to 3) MRSA MSSA VRE
CephR-Klebsiella CRE-Ecoli CRE-Klebsiella MDR-Acinetobacter C. difficile
|
*Date Admitted to Facility:
| *Location
|
*Specific Event Type (used only for CDC defined events):
|
Specify Criteria Used (check all that apply) Signs & Symptoms
Abscess Apnea Vomiting Bradycardia Redness Cough Dysuria Fever Acute onset of diarrhea (liquid stools for > 12 hours) Purulent drainage or material Pain or tenderness New onset/change in sputum, increased secretions
or increased suctioning
Localized swelling Persistent microscopic or gross blood in stools Wheezing, rales or rhonchi Other evidence of infection found on direct exam,
during surgery or by diagnostic testing+
|
Laboratory or Diagnostic Testing
□ Positive culture □ Not cultured □ Positive blood culture □ Blood culture not done or no organisms detected in blood
not done
semiquantitative culture method
Positive culture of pathogen Positive culture of skin contaminant Other positive laboratory tests Radiographic evidence of infection
Clinical Diagnosis
therapy+ + Per specific event criteria
|
Clostridium difficile Infection
|
*Admitted to ICU for CDI complications: Yes No
| *Surgery for CDI complications: Yes No
|
*Secondary Bloodstream Infection: Yes No
| |
**Died: Yes No
| Event contributed to death? Yes No
|
Discharge Date: ____/____/________ *Pathogens Identified: Yes No If Yes, specify on page 2
|
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 57.126 (Front) v6.4
|
