Att G.5 DEMO

NHSN Patient Safety Component
Tables of Instructions

Tables of Instructions
Table
1

CDC Form
57.106

2

57.108

2a
3

All NHSN
event forms
57.125

4
5

57.111
57.114

6

57.118

7

57.117

8

57.116

9

57.109

Title
Instructions for Completion of the Patient Safety Monthly
Reporting Plan Form
Instructions for Completion of the Primary Bloodstream
Infection (BSI) Form
Instructions for Completion of Pathogen Information on Event
Forms
Instructions for Completion of the Central Line Insertion
Practices (CLIP) Adherence Monitoring Form
Instructions for Completion of the Pneumonia (PNEU) Form
Instructions for Completion of the Urinary Tract Infection
(UTI) Form
Instructions for Completion of the Denominators for
Intensive Care Unit (ICU)/Other locations (not NICU or
SCA) Form
Instructions for Completion of the Denominators for
Specialty Care Area (SCA) Form
Instructions for Completion of the Denominators for
Neonatal Intensive Care Unit (NICU) Form

Page
3
7
11
12
15
18
21

23
25
-

For Instructions for Completion of the Denominators for
Outpatient Dialysis: Dialysis event (DE) Form see
http://www.cdc.gov/nhsn/psc_da_de.html
10

57.119

For instruction for Completion of the Dialysis Census Form
see http://www.cdc.gov/nhsn/psc_da_de.html

11
12

57.123
57.124
57.120

13

57.121

14

57.130

15

57.131

16
17
18

57.132
57.133
57.134

19

57.128

January 2012

Instructions for Completion of the AUR Option of the
Medication-Associated Module

29

Instructions for Completion of the Surgical Site Infection
(SSI) Form
Instructions for Completion of the Denominator for
Procedure Form
Instructions for Completion of the Vaccination Monthly
Monitoring Form – Summary Method
Instructions for Completion of the Vaccination Monthly
Monitoring Form – Patient-Level Method
This form has been retired and is no longer used.
Instructions for Completion of the Patient Vaccination Form
Instructions for Completion of the Influenza Vaccination
Standing Orders – Optional Form
Instructions for Completion of the Laboratory-identified

30

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37
39
–
41
43
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NHSN Patient Safety Component
Tables of Instructions

Table

CDC Form

20

57.126

21

57.127

January 2012

Title
(LabID) MDRO or CDI Event Form
Instructions for Completion of the MDRO or CDI Infection
Event Form
Instructions for Completion of the MDRO and CDI
Prevention Process and Outcome Measures Monthly
Monitoring Form

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NHSN Patient Safety Component
Tables of Instructions

Table 1. Instructions for Completion of the Patient Safety Monthly
Reporting Plan Form (CDC 57.106) (Tables of Instructions List)
Data Field
Facility ID #
Month/Year

Instructions for Form Completion
The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Enter the month and year for the surveillance plan being
recorded; use MM/YYYY format.
No NHSN Patient Safety Conditionally required. Check this box if you do not plan to follow
Modules Followed this any of the NHSN Patient Safety Modules during the month and year
Month
selected.
Device-Associated Module
Locations
Conditionally required. If you plan to follow device-associated
events, enter the location codes for those facility locations where
patients are housed overnight and from which you will collect
denominator data (i.e., inpatient locations). If you plan to follow CLIP
(see below), any type of patient care location where central lines are
inserted may be entered.
CLABSI
Conditionally required. If you plan to follow device-associated
events, check this box if you will collect central line-associated
bloodstream infection (CLABSI) data and corresponding summary
(denominator) data for the location in the left column.
DE
Conditionally required. If you plan to follow device-associated
events, check this box if you will collect dialysis event (DE) data and
corresponding summary (denominator) data for the outpatient dialysis
location in the left column.
VAP
Conditionally required. If you plan to follow device-associated
events, check this box if you will collect ventilator-associated
pneumonia (VAP) data and corresponding summary (denominator)
data for the location in the left column.
CAUTI
Conditionally required. If you plan to follow device-associated
events, check this box if you will collect catheter-associated urinary
tract infection (CAUTI) data and corresponding summary
(denominator) data for the location in the left column.
CLIP
Conditionally required. Check this box if you will collect central line
insertion practice (CLIP) data for the location indicated in the left
column. These locations may be any type of patient care area where
central lines are inserted (e.g., ward, OR, ED, ICU, outpatient clinic,
etc.).
Procedure-Associated Module
Procedures
Conditionally required. If you plan to follow procedure-associated
events, list the procedure codes for those NHSN operative procedures
for which you will collect data about selected procedure-associated
events and procedure-level denominator data.
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Tables of Instructions

Data Field
SSI (Circle one setting)

Instructions for Form Completion
Conditionally required. For each selected NHSN operative procedure
in the left column, if you plan to follow SSIs, choose the patient
population for which you will monitor this procedure. Circle “In” to
follow only inpatients, circle “Out” to follow only outpatients, or
circle “Both” to follow inpatients and outpatients. If SSIs will not be
monitored for a listed procedure for this month, do not circle any of
the choices.
Post-procedure PNEU
Conditionally required. For each selected NHSN operative procedure
in the left column, if you plan to follow post-procedure pneumonia
(PPP), circle “In”. If you do not monitor PPP, leave this unmarked.
NOTE: Inpatient (“In”) is the only setting option for monitoring postprocedure pneumonia.
Medication-Associated Module: Antimicrobial Use and Resistance
Locations
Conditionally required. If you plan to follow the antimicrobial use
and/or resistance (AUR) options, enter the location codes for those
facility locations from which you will collect data about antimicrobial
use and/or resistance.
Antimicrobial Use
Conditionally required. Check if you will submit antimicrobial use
data for the selected location.
Antimicrobial Resistance Conditionally required. Check if you will submit antimicrobial
resistance data for the selected location.
MDRO and CDI Module
For reporting overall facility-wide data:
Locations
Conditionally required. Choose either FacWideIN, to perform overall
(FacWideIN/OUT)
facility-wide surveillance for all inpatient locations, or FacWideOUT,
to perform overall facility-wide surveillance for all outpatient
locations, if you plan to perform LabID Event reporting for an
organism at the facility-wide level, instead of by location (i.e., using
Methods C or D). To report LabID Events from both overall facilitywide inpatient and outpatient locations, you must choose both
FacWideIN and FacWideOUT. (These will be added on two separate
rows.)
Specific Organism Type Conditionally required. Enter each organism you will be following for
LabID Event reporting at the facility-wide level: MRSA,
MRSA/MSSA, VRE, CephR-Klebsiella spp., CRE-E. coli, CREKlebsiella spp., MDR-Acinetobacter spp. and/or C. difficile.
LabID Event
Conditionally required. Choose whether you plan to report the
(All specimens or Blood specific MDRO as LabID Events at the facility-wide level for All
specimens only)
specimens or for Blood specimens only. C. difficile must be reported
for All specimens for LabID Event reporting at the facility-wide level.
Locations
Conditionally required. If you plan to perform Infection Surveillance
and/or LabID Event reporting by specific location (i.e., Methods A or

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NHSN Patient Safety Component
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Data Field

Instructions for Form Completion
B), or if you plan to monitor process and/or outcome measures, then
indicate the location(s) where specific monitoring will occur. You
must add/complete a row for a second and each subsequent location.
Specific Organism Type Conditionally required. Enter the organism you will be monitoring for
a specific location: MRSA, MRSA/MSSA, VRE, CephR-Klebsiella
spp., CRE-E. coli, CRE-Klebsiella spp., MDR-Acinetobacter spp.
and/or C. difficile. If you plan to monitor more than one organism in a
location, then a separate row must be completed for each organism for
that location.
Infection Surveillance
Conditionally required. For the given location and organism, indicate
if you plan to participate in Infection Surveillance. Infection
Surveillance or LabID Event reporting in at least one patient care area
is required for each organism your facility chooses to monitor
(MRSA, MRSA/MSSA, VRE, CephR-Klebsiella spp., CRE-E. coli,
CRE-Klebsiella spp., MDR-Acinetobacter spp. and/or C. difficile).
AST
Conditionally required. For the given location and MRSA or VRE, if
Timing
you plan to perform active surveillance testing (AST) for MRSA or
VRE, indicate whether testing will be done on admission (Adm) only
or at admission and at discharge/transfer (Both).
AST
Conditionally required. For the given location and MRSA or VRE,
Eligible
circle “All” if all patients will be eligible for AST, or, circle “NHx” to
indicate that the only patients eligible for testing will be those with no
history of MRSA or VRE colonization or infection in the past 12
months as documented by the admitting facility.
Incidence
Conditionally required. Select if you plan to report incidence of the
organism (MRSA or VRE) at the location listed in the left column
using AST and clinical positives.
Prevalence
Conditionally required. Select if you plan to report prevalence of the
organism (MRSA or VRE) at the location listed in the left column
using AST, clinical positive, and known positives.
LabID Event
Conditionally required. For the given location and organism, indicate
(All Specimens)
if you plan to monitor for Laboratory-identified (LabID) Events.
Infection Surveillance or LabID Event reporting in at least one patient
care area is required for each organism your facility chooses to
monitor (MRSA, MRSA/MSSA, VRE, CephR-Klebsiella spp., CREE. coli, CRE-Klebsiella spp., MDR-Acinetobacter spp. and/or C.
difficile).
HH
Conditionally required. Select this if you plan to monitor Hand
Hygiene adherence in the location specified. Ideally, this should be
the patient care location(s) also selected for MDRO or C. difficile
surveillance.
GG
Conditionally required. Select this if you plan to monitor gown and
gloves use adherence in the location specified. Ideally, this should be
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Tables of Instructions

Data Field

Summary-Method or
Patient-level Method:

January 2012

Instructions for Form Completion
the patient care location(s) also selected for MDRO or C. difficile
surveillance.
Vaccination Module
Conditionally required. If you plan to follow this module, select either
Summary-Method or Patient-level Method.

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Tables of Instructions

Table 2. Instructions for Completion of the Primary Bloodstream
Infection (BSI) Form (CDC 57.108) (Tables of Instructions List)
Data Field
Facility ID #
Event #
Patient ID #

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer.
Event ID number will be auto-entered by the computer.
Required. Enter the alphanumeric patient ID number. This is the patient
identifier assigned by the hospital and may consist of any combination of
numbers and/or letters.
Social Security #
Optional. Enter the 9-digit numeric patient Social Security Number.
Secondary ID #
Optional. Enter the alphanumeric ID number assigned by the facility.
Medicare #
Optional. Enter the patient’s Medicare number.
Patient name
Optional. Enter the last, first, and middle name of the patient.
Gender
Required. Check Female, Male, or Other to indicate the gender of the
patient.
Date of Birth
Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Ethnicity
Optional.
Hispanic or Latino If patient is Hispanic or Latino, check this box.
Not Hispanic or Not Latino If patient is not Hispanic or not Latino, check this box.
Race
Optional. Check all the boxes that apply to identify the patient’s race.
Event type
Required. BSI.
Date of event
Required. The date when the first clinical evidence of the BSI appeared or
the date the blood culture was collected, whichever comes first. Enter date
of this event using this format: MM/DD/YYYY. NOTE: If a device has
been pulled on the first day of the month in a location where there are no
other device days in that month, and a device-associated infection
develops after the device is pulled, attribute the infection to the previous
month.
Post-procedure BSI
Optional. Check Y if this event occurred after an NHSN defined
procedure but before discharge from the facility, otherwise check N.
NHSN procedure code
Conditionally required. If Post-procedure BSI = Y, enter the appropriate
NHSN procedure code.
NOTE: A BSI cannot be “linked” to an operative procedure unless that
procedure has already been added to NHSN. If the procedure was
previously added, and the “Link to Procedure” button is clicked, the fields
pertaining to the operation will be auto-entered by the computer.
ICD-9-CM procedure code
Optional. The ICD-9-CM code may be entered here instead of (or in
addition to) the NHSN Procedure Code. If the ICD-9-CM code is entered,
the NHSN code will be auto-entered by the computer. If the NHSN code

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Tables of Instructions

Data Field

Instructions for Data Collection
is entered first, you will have the option to select the appropriate ICD-9CM code. In either case, it is optional to select the ICD-9-CM code. Only
those ICD-9-CM codes identified in Table 1 of the Surgical Site Infection
Event Chapter (Chapter 9 of NHSN Manual: Patient Safety Component
Protocol) are allowed.
MDRO infection
Required. Enter “Yes”, if the pathogen is being followed for Infection
Surveillance in the MDRO/CDI Module in that location as part of your
Monthly Reporting Plan: MRSA, MSSA (MRSA/MSSA), VRE, CephRKlebsiella, CRE-E. coli, CRE-Klebsiella, MDR-Acinetobacter or C.
difficile.
If the pathogen for this infection happens to be an MDRO but your facility
is not following the Infection Surveillance in the MDRO/CDI Module in
your Monthly Reporting Plan, answer “No” to this question.
Location
Required. Enter the inpatient location to which the patient was assigned
when the BSI was identified.
If the BSI develops in a patient within 48 hours of transfer from a
location, indicate the transferring location, not the current location of the
patient, in accordance with the Transfer Rule (see Key Terms section).
Date admitted to facility
Required. Enter date patient admitted to facility using this format:
MM/DD/YYYY. An NHSN Inpatient is defined as a patient whose date of
admission to the healthcare facility and the date of discharge are different
calendar days. When determining a patient’s admission dates to both the
facility and specific inpatient location, the NHSN user must take into
account all such days, including any days spent in an inpatient location as
an “observation” patient before being officially admitted as an inpatient to
the facility, as these days contribute to exposure risk. Therefore, all such
days are included in the counts of admissions and patient days for the
facility and specific location, and facility and admission dates must be
moved back to the first day spent in the inpatient location.
Risk Factors:
Required. Answer this question if the location is an intensive care unit
If ICU/Other locations, central (ICU) or location other than a specialty care area (SCA) or neonatal
line
intensive care unit (NICU). Check Y if patient had a central line during
the 48 hour period before event date, otherwise check N.
NOTE: If the patient has both a peripheral and a central line and the BSI
can clearly be attributed to the peripheral line (e.g., pus at insertion site
and matching pathogen from pus and blood), check N.

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NHSN Patient Safety Component
Tables of Instructions

Data Field
Risk Factors:
If Specialty Care Area,
Permanent central line

Temporary central line

Instructions for Data Collection
Required. Answer these questions if the location is an SCA:
Check Y if patient had a tunneled or implanted central line during the 48hour period before event date, otherwise check N.
Check Y if patient had a non-tunneled central line during the 48-hour
period before event date, otherwise check N.
NOTE: If the patient has both a peripheral and a central line and the BSI
can clearly be attributed to the peripheral line (e.g., pus at insertion site
and matching pathogen from pus and blood), check N.
Required. Answer these questions if the location is an NICU: Check Y if
patient had a non-umbilical central line during the 48-hour period before
event date, otherwise check N.

Risk Factors:
If NICU,
Central line

Required. Enter patient’s weight at the time of birth in grams, not the
weight on the date of event.
Birthweight

Location of device insertion

Date of device insertion

Event Details:
Specific event
Event Details
Specify criteria used:
Event Details:
Died
Event Details:
BSI contributed to death
Event Details:
Discharge date
Event Details:
Pathogen identified

January 2012

NOTE: If the patient has both a peripheral and a central line and the BSI
can clearly be attributed to the peripheral line (e.g., pus at insertion site
and matching pathogen from pus and blood), check N.
Optional. Enter the patient location where the central line was inserted.
• If the patient has more than one central line, enter the location
where the first central line was inserted.
• If the patient has both a permanent and a temporary central line,
enter the location where the temporary line was inserted.
Optional. Enter the date the central line was inserted. If the patient has
more than one central line, enter the insertion date for the first line that
was inserted.
Required. Check Laboratory-confirmed (LCBI).
Required. Check each of the elements of the criterion that was used to
identify this infection.
Required. Check Y if patient died during the hospitalization, otherwise
check N.
Conditionally required if patient died. Check Y if the BSI contributed to
death, otherwise check N.
Optional. Date patient discharged from facility using this format:
MM/DD/YYYY.
Required. This field will be auto entered by the computer as Y. Specify
pathogens on reverse of form (see Table 2a for instructions).

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NHSN Patient Safety Component
Tables of Instructions

Data Field
Custom Fields

Comments

January 2012

Instructions for Data Collection
Optional. Up to 50 fields may be customized for local or group use in any
combination of the following formats: date (MMDDYYY), numeric, or
alphanumeric.
NOTE: Each custom field must be set up in the Facility/Custom Options
section of the application before the field can be selected for use.
Optional. Enter any information on the event.

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NHSN Patient Safety Component
Tables of Instructions

Table 2a. Instructions for Completion of the Back of the Following
Forms: Primary Bloodstream Infection (CDC 57.108); Pneumonia
(CDC 57.111); Urinary Tract Infection (CDC 57.114); Surgical Site
Infection (CDC 57.120); Dialysis Event (CDC 57.109); MDRO and
CDI Infection Event (CDC 57.126) (Tables of Instructions List)
Data Field
For specified Gram-positive,
organisms, Gram-negative
organisms, or other organisms,
Pathogen #

Instructions for Data Collection/Entry
Up to three pathogens may be reported. If multiple pathogens are
identified, enter the pathogen judged to be the most important cause of
infection as #1, the next most as #2, and the least as #3 (usually this order
will be indicated on the laboratory report). If the species is not given on
the lab report or is not found on the NHSN drop down list, then select the
“spp” choice for the genus (e.g., Bacillus cohnii would be reported as
Bacillus spp.).
If the event reported is an ABUTI, then pathogen #1 must be an
uropathogen. (Uropathogen microorganisms are: Gram-negative bacilli,
Staphylococcus spp., yeasts, beta-hemolytic Streptococcus spp.,
Enterococcus spp., G. vaginalis, Aerococcus urinae, and Corynebacterium
(urease positive)+.
Note:** +Report Corynebacterium (unrease positive) as either
Corynebacterium species unspecified (COS) or, as C. urealyticum
(CORUR) if so speciated.)

Antimicrobial agent and
susceptibility results

Conditionally required if Pathogen Identified = Y.
• For those organisms shown on the back of an event form,
susceptibility results are required only for the agents listed.
• For organisms that are not listed on the back of an event form,
enter a susceptibility result for at least one antimicrobial agent,
even if that result is “Not Tested”.
Circle the pathogen’s susceptibility result using the codes on the event
forms.
Additional antimicrobial agents and susceptibility results may be
reported for up to a total of 20 agents.

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NHSN Patient Safety Component
Tables of Instructions

Table 3. Instructions for Completion of the Central Line Insertion
Practices Adherence Monitoring Form (CDC 57.125) (Tables of Instructions
List)

Data Field
Facility ID

Instructions for Form Completion
The NHSN-assigned facility ID will be auto-entered by the computer.

Event #

Event ID number will be auto-entered by the computer.

Patient ID

Required. Enter the alphanumeric patient ID number. This is the
patient identifier assigned by the hospital and may consist of any
combination of numbers and/or letters.
Optional. Enter the 9-digit numeric patient Social Security Number.
Optional. Enter the alphanumeric ID number assigned by the facility.
Optional. Enter the patient’s Medicare number.
Optional. Enter the last, first, and middle name of the patient.

Social Security #
Secondary ID
Medicare #
Patient name: Last, first,
middle
Gender

Required. Check Female, Male or Other to indicate the gender of the
patient.
Date of Birth
Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Ethnicity
Optional.
Hispanic or Latino If patient is Hispanic or Latino, check this box.
Not Hispanic or Not Latino If patient is not Hispanic or not Latino, check this box.
Race (specify)
Optional. Check all the boxes that apply to identify the patient’s race.
Event Type
Required. CLIP.
Location
Required. Enter the location of the patient at the time of the central
line insertion.
Date of insertion
Required. Enter the date of central line insertion (MM/DD/YYYY).
Person recording insertion Required. Select inserter or observer.
practice data
Central line inserter ID
Optional. Enter the HCW ID# of the person inserting the central line.
Name, Last, First
Optional. Enter last name and first name of person inserting the
central line.
Occupation of inserter
Required. Check the occupational category of the person inserting the
central line Fellow; IV Team; Medical Student; Other Medical Staff;
Physician Assistant; Attending physician; Intern/Resident; Other
student; PICC Team. If Other than these, please specify.
Reason for insertion
Required. Check the primary reason for inserting the central line: New
indication (e.g., hemodynamic monitoring, fluid/medication administration,

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Tables of Instructions

Data Field

Instructions for Form Completion
etc.); Replace malfunctioning central line; Suspected central line-

associated infection. If Other, please specify.
If Suspected central line- Conditionally required. Answer this only if reason for insertion is
associated infection, was suspected central line-associated infection. Check Y if the central line
the central line exchanged was exchanged over a guidewire; otherwise Check N.
over a guidewire?
Inserter performed hand
Required. Check Y if the inserter appropriately performed hand
hygiene prior to central line hygiene prior to inserting central line; otherwise check N. Appropriate
insertion
hand hygiene includes the use of alcohol-based hand rub or soap and
water hand wash. If not observed directly, ask inserter.
Maximal sterile barriers
Required. Indicate whether each of the 5 barriers was used
used
appropriately, by checking Y or N.
NOTE: If inserter wore either a mask or a mask with eye shield, the Y
box for Mask should be checked.
Skin preparation
Required. Check all that apply: Chlorhexidine gluconate; Povidone
iodine; Alcohol; Other. If Other is chosen, specify prep used.
Was skin preparation agent Required. Check Y if the skin prep agent was allowed to dry
completely dry at time of completely at the time of first skin puncture; otherwise select N. If not
first skin puncture?
observed directly, ask inserter.
Insertion site
Required. Check the site of insertion of the central line: Femoral;
Jugular; Lower extremity; Scalp; Subclavian; Umbilical; Upper
extremity.
Antimicrobial coated
Optional. Check Y if antimicrobial coated catheter was used;
catheter used
otherwise check N.
Central line catheter type Required. Check the type of central line inserted:
Dialysis non-tunneled; Dialysis tunneled; Non-tunneled (other than
dialysis); Tunneled (other than dialysis); PICC; Umbilical. If other,
please specify. ‘Other’ should only be marked when none of the other
options apply. It should not be used to specify brand names or
number of lumens. Most lines can be categorized accurately by
selecting from the options provided.
Did this insertion attempt Required. Check Y if attempt was successful; otherwise check N.
result in a successful
central line placement?
Custom Fields

Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYY),
numeric, or alphanumeric.
NOTE: Each custom field must be set up in the Facility/Custom
Options section of the application before the field can be selected for

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Tables of Instructions

Data Field
Comments

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Instructions for Form Completion
use.
Optional. Enter any additional information on the central line
insertion.

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Tables of Instructions

Table 4. Instructions for Completion of Pneumonia (PNEU) Form
(CDC 57.111) (Tables of Instructions List)
Data Field
Facility ID #
Event #
Patient ID #

Social Security #
Secondary ID #
Medicare #
Patient name
Gender
Date of birth
Ethnicity
Hispanic or Latino
Not Hispanic or Not
Latino
Race
Event type
Date of event

Post-procedure PNEU
Date of procedure
NHSN procedure code

January 2012

Instructions for Data Collection
The NHSN-assigned facility ID will be auto entered by the
computer.
Event ID number will be auto entered by the computer.
Required. Enter the alphanumeric patient ID number. This is the
patient identifier assigned by the hospital and may consist of any
combination of numbers and/or letters.
Optional. Enter the 9-digit numeric patient Social Security Number.
Optional. Enter the alphanumeric ID number assigned by the
facility.
Optional. Enter the patient’s Medicare number.
Optional. Enter the last, first, and middle name of the patient.
Required. Check Female, Male, or Other to indicate the gender of
the patient.
Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Optional.
If patient is Hispanic or Latino, check this box.
If patient is not Hispanic or not Latino, check this box.
Optional.
Check all the boxes that apply to identify the patient’s race.
Required. PNEU.
Required. The date when the first clinical evidence of the PNEU
appeared or the date the specimen used to make or confirm the
diagnosis was collected, whichever comes first. Enter date of this
event using this format: MM/DD/YYYY. NOTE: If a device has
been pulled on the first day of the month in a location where there
are no other device days in that month, and a device-associated
infection develops after the device is pulled, attribute the infection to
the previous month.
Required. Check Y if this event occurred after an NHSN defined
procedure but before discharge from the facility, otherwise check N.
Conditionally required. If Post-procedure PNEU = Y, then enter the
date the procedure was done.
Conditionally required. Answer this question only if this patient
developed the PNEU during the same admission as an operative

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Data Field

ICD-9-CM procedure
code

MDRO infection

Location

Date admitted to facility

Instructions for Data Collection
procedure. Enter the appropriate NHSN procedure code.
NOTE: A PNEU cannot be “linked” to an operative procedure
unless that procedure has already been added to NHSN. If the
procedure was previously added, and the “Link to Procedure” button
is clicked, the fields pertaining to the operation will be auto entered
by the computer.
Optional. The ICD-9-CM code may be entered here instead of (or in
addition to) the NHSN Procedure Code. If the ICD-9-CM code is
entered, the NHSN code will be auto entered by the computer. If the
NHSN code is entered first, you will have the option to select the
appropriate ICD-9-CM code. In either case, it is optional to select
the ICD-9-CM code. Only those ICD-9-CM codes identified in
Table 1 of the Surgical Site Infection Event Chapter (Chapter 9 of
NHSN Manual: Patient Safety Component Protocol) are allowed.
Required. Enter “Yes”, if the pathogen is being followed for
Infection Surveillance in the MDRO/CDI Module in that location as
part of your Monthly Reporting Plan: MRSA, MSSA
(MRSA/MSSA), VRE, CephR-Klebsiella, CRE-E. coli, CREKlebsiella, MDR-Acinetobacter or C. difficile.
If the pathogen for this infection happens to be an MDRO but your
facility is not following the Infection Surveillance in the
MDRO/CDI Module in your Monthly Reporting Plan, answer “No”
to this question.
Required. Enter the inpatient location to which the patient was
assigned when the PNEU was identified. If the PNEU develops in a
patient within 48 hours of transfer from a location, indicate the
transferring location, not the current location of the patient.
Required. Enter date patient admitted to facility using this format:
MM/DD/YYYY. An NHSN Inpatient is defined as a patient whose
date of admission to the healthcare facility and the date of discharge are
different calendar days. When determining a patient’s admission
dates to both the facility and specific inpatient location, the NHSN
user must take into account all such days, including any days spent
in an inpatient location as an “observation” patient before being
officially admitted as an inpatient to the facility, as these days
contribute to exposure risk. Therefore, all such days are included in
the counts of admissions and patient days for the facility and
specific location, and facility and admission dates must be moved
back to the first day spent in the inpatient location.

Risk Factors
Ventilator Required. Check Y if the patient with PNEU had a device to assist
or control respiration continuously through a tracheostomy or by
endotracheal intubation, inclusive of the weaning period, within the

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Data Field

Instructions for Data Collection
48-hour period before developing infection, otherwise check N.

Birth weight Conditionally required. If the patient is a NICU patient, enter the
patient’s birth weight in grams, not the weight on the date of event.
Location of device
Optional. Enter the patient location where the intubation and
insertion
ventilation procedure was performed
Date of device insertion Optional. Enter the date the intubation and ventilation procedure
was performed.
Event Details: PNEU
Required. Check one: Clinically Defined Pneumonia (PNU1),
Specific event
Pneumonia with specific laboratory findings (PNU2), or Pneumonia
in immunocompromised patients (PNU3), whichever criteria are met
for this event.
Event Details:
Required. Check each of the elements that were used to identify this
Specify criteria used
infection.
Event Details:
Required. Check Y if there is a culture-confirmed bloodstream
Secondary bloodstream
infection (BSI) and a related pneumonia, otherwise check N.
infection
Event Details:
Required. Check Y if patient died during the hospitalization,
Died
otherwise check N.
Event Details:
Conditionally required. If the patient died, check Y if the PNEU
PNEU contributed to
contributed to death, otherwise check N.
death
Event Details:
Optional. Date patient discharged from facility.
Discharge date
Event Details:
Required. This field will be auto entered by the computer as Y.
Pathogen identified
Specify pathogens on reverse form (see Table 2a for instructions).
Custom Fields
Optional. Up to 50 fields may be customized for local or group use
in any combination of the following formats: date (MMDDYYY),
numeric, or alphanumeric.

Comments

January 2012

NOTE: Each Custom Field must be set up in the Facility/Custom
Options section of the application before the field can be selected for
use.
Optional. Enter any information on the event.

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Table 5. Instructions for Completion of Urinary Tract Infection (UTI)
Form (CDC 57.114) (Tables of Instructions List)
Data Field
Facility ID #
Event #
Patient ID #

Instructions for Data Collection/Entry
The NHSN-assigned facility ID will be auto-entered by the computer.
Event ID number will be auto-entered by the computer.
Required. Enter the alphanumeric patient ID number. This is the patient
identifier assigned by the hospital and may consist of any combination of
numbers and/or letters.
Social Security #
Optional. Enter the 9-digit numeric patient Social Security Number.
Secondary ID #
Optional. Enter the alphanumeric ID number assigned by the facility.
Medicare #
Optional. Enter the patient’s Medicare number.
Patient name
Optional. Enter the last, first, and middle name of the patient.
Gender
Required. Check Female, Male, or Other to indicate the gender of the
patient.
Date of birth
Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Ethnicity
Optional.
Hispanic or Latino If patient is Hispanic or Latino, check this box.
Not Hispanic or Not If patient is not Hispanic or not Latino, check this box.
Latino
Race
Optional.
Check all the boxes that apply to identify the patient’s race.
Event type
Required. UTI.
Date of event
Required. The date when the first clinical evidence of the UTI appeared
or the date the specimen used to make or confirm the diagnosis was
collected, whichever comes first. Enter date of this event using this
format: MM/DD/YYYY. NOTE: If a device has been pulled on the first
day of the month in a location where there are no other device days in
that month, and a device-associated infection develops after the device is
pulled, attribute the infection to the previous month.
Post-procedure UTI
Optional. Check Y if this event occurred after an NHSN defined
procedure but before discharge from the facility, otherwise check N.
Date of procedure
Conditionally required. If Post-procedure UTI = Y, enter the date the
procedure was done.
NHSN procedure code
Conditionally required. If Post-procedure UTI = Y, enter the appropriate
NHSN procedure code.
NOTE: A UTI cannot be “linked” to an operative procedure unless that
procedure has already been added to NHSN. If the procedure was
previously added, and the “Link to Procedure” button is clicked, the

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Data Field

Instructions for Data Collection/Entry
fields pertaining to the operation will be auto-entered by the computer.
ICD-9-CM procedure
Optional. The ICD-9-CM code may be entered here instead of (or in
code
addition to) the NHSN Procedure Code. If the ICD-9-CM code is
entered, the NHSN code will be auto-entered by the computer. If the
NHSN code is entered first, you will have the option to select the
appropriate ICD-9-CM code. In either case, it is optional to select the
ICD-9-CM code. Only those ICD-9-CM codes identified in Table 1 of
the Surgical Site Infection Event Chapter (Chapter 9 of NHSN Manual:
Patient Safety Component Protocol) are allowed.
MDRO infection
Required. Enter “Yes”, if the pathogen is being followed for Infection
Surveillance in the MDRO/CDI Module in that location as part of your
Monthly Reporting Plan: MRSA, MSSA (MRSA/MSSA), VRE, CephRKlebsiella, CRE-E. coli, CRE-Klebsiella, MDR-Acinetobacter or C.
difficile.
If the pathogen for this infection happens to be an MDRO but your
facility is not following the Infection Surveillance in the MDRO/CDI
Module in your Monthly Reporting Plan, answer “No” to this question.
Location
Required. Enter the inpatient location to which the patient was assigned
when the UTI was identified. If the UTI develops in a patient within 48
hours of transfer from a location, indicate the transferring location, not
the current location of the patient.
Date admitted to facility
Required. Enter date patient admitted to facility using this format:
MM/DD/YYYY. An NHSN Inpatient is defined as a patient whose date of
admission to the healthcare facility and the date of discharge are different
calendar days. When determining a patient’s admission dates to both the
facility and specific inpatient location, the NHSN user must take into
account all such days, including any days spent in an inpatient location as
an “observation” patient before being officially admitted as an inpatient
to the facility, as these days contribute to exposure risk. Therefore, all
such days are included in the counts of admissions and patient days for
the facility and specific location, and facility and admission dates must
be moved back to the first day spent in the inpatient location.
Risk factor:
Required. Check “In place” if urinary catheter was in place at time of
Urinary catheter status at
urine specimen collection or onset of signs and symptoms; Check
time of specimen
“Removed within 48 hours prior” if a urinary catheter was removed
collection or onset of signs within the 48 hours before urine specimen was collected or onset of signs
or symptoms
and symptoms; Check “Not in place nor within 48 hours prior” if no
urinary catheter was in place at the time of or within the 48 hours prior to
urine specimen collection.
Location of device
Optional. Enter the patient location where the indwelling urethral
insertion
catheter was inserted.
Date of device insertion
Optional. Enter the date the indwelling urethral catheter was inserted.
Event details:
Required. Check Symptomatic UTI (SUTI), Asymptomatic Bacteremic

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Data Field
Specific event: UTI
Event details: UTI
Specify criteria used
Event Details: Secondary
bloodstream infection
Event Details:
Died
Event Details:
UTI contributed to death
Event Details:
Discharge date
Event Details:
Pathogens identified

Custom Fields

Comments

January 2012

Instructions for Data Collection/Entry
UTI (ABUTI), or Other UTI (OUTI), for the specific event type you are
reporting.
Required. Check each of the elements of the criteria that were used to
identify the specific type of UTI being reported.
Required. Check Y if there is a culture-confirmed bloodstream infection
(BSI) and a related healthcare-associated UTI, otherwise check N.
Required. Check Y if patient died during the hospitalization, otherwise
check N.
Conditionally required. If patient died, check Y if the UTI contributed to
death, otherwise check N.
Optional. Date patient discharged from facility.
Required. Enter Y if pathogen identified, N if otherwise. If Y, specify
pathogens on reverse of form (see Table 2a for instructions). For SUTI
with secondary BSI and ABUTI, enter only the matching organism(s)
identified in both urine and blood cultures (See Table 2a for instructions).
For ABUTI, the organism listed as pathogen number 1, must be an
uropathogen (See ABUTI criterion).
Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYY), numeric,
or alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom
Options section of the application before the field can be selected for use.
Optional. Enter any information on the event.

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Table 6. Instructions for the Completion of Denominators for Intensive
Care Unit (ICU)/Other Locations (Not NICU or SCA) (CDC 57.118)
(Tables of Instructions List)

Data Field
Facility ID #
Location code
Month
Year
Number of patients
Number of patients with 1
or more central lines

Number of patients with a
urinary catheter

Number of patients on a
ventilator

January 2012

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Enter the location code of the unit where you collect the
data.
Required. Record the 2-digit month during which the data were
collected for this location.
Required. Record the 4-digit year during which the data were collected
for this location.
Required. For each day of the month selected, record the number of
patients on the unit. Record this number at the same time each day.
Conditionally required. Complete if you have chosen central lineassociated bloodstream infection (CLABSI) as an event to follow in
your Plan for this month.
For each day of the month, at the same time each day, record the
number of patients on the selected unit who have 1 or more central
lines. NOTE: “If the patient has only a tunneled or implanted central
line, begin recording days on the first day the line was accessed and
continue until the line is discontinued or the patient is
transferred/discharged.”
NOTE: If a device has been pulled on the first day of the month in a
location where there are no other device days in that month, and a
device-associated infection develops after the device is pulled, attribute
the infection to the previous month.
Conditionally required. Complete if you have chosen catheterassociated urinary tract infection (CAUTI) as an event to follow in your
Plan for this month.
For each day of the month, at the same time each day, record the
number of patients on the selected unit who have an indwelling urinary
catheter. NOTE: If a device has been pulled on the first day of the
month in a location where there are no other device days in that month,
and a device-associated infection develops after the device is pulled,
attribute the infection to the previous month.
Conditionally required. Complete if you have chosen ventilatorassociated pneumonia (VAP) as an event to follow in your Plan for this
month.
For each day of the month, at the same time each day, record the
number of patients on the selected unit who are on a ventilator. NOTE:
If a device has been pulled on the first day of the month in a location

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Data Field

Total
Report No Events

Custom Fields

Instructions for Data Collection
where there are no other device days in that month, and a deviceassociated infection develops after the device is pulled, attribute the
infection to the previous month.
Required. Totals for each column should be calculated. This is the
number that will be entered into the NHSN application.
While not on the paper data collection form, when completing summary
data entry on-line, if no events included on your monthly reporting plan
are reported, you will be required to check the appropriate Report No
Events box(es), i.e., CLABSI, CAUTI, VAP.
Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYY),
numeric, or alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom
Options section of NHSN before the field can be selected for use.

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Table 7. Instructions for Completion of the Denominators for Specialty
Care Area (SCA) (CDC 57.117) (Tables of Instructions List)
Data Field
Facility ID #
Location code
Month
Year
Number of patients
Number of patients
with 1 or more
central lines

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer
Required. Enter the location code of the unit where you collect the data.
Required. Record the 2-digit month during which the data were
collected for this location.
Required. Record the 4-digit year during which the data were collected
for this location.
Required. For each day of the month selected, record the number of
patients on the unit. Record this number at the same time each day.
Conditionally required. Complete if you have chosen central lineassociated bloodstream infection (CLABSI) as an event to follow in your
Plan for this month.

Temporary For each day of the month, at the same time each day, record the number
of patients on the selected unit who have 1 or more non-tunneled central
lines.
Permanent For each day of the month, at the same time each day, record the number
of patients on the selected unit who have 1 or more tunneled or
implanted central lines beginning on the first day the permanent line was
accessed and continuing until the line is discontinued or the patient is
transferred/discharged.

Number of patients
with a urinary
catheter

Number of patients
on a ventilator

Total
Report No Events

January 2012

NOTE: If a patient has both a temporary and a permanent line in place,
count only the temporary line.
Conditionally required. Complete if you have chosen catheter-associated
urinary tract infection (CAUTI) as an event to follow in your Plan for
this month.
For each day of the month, at the same time each day, record the number
of patients on the selected unit who have an indwelling urinary catheter.
Conditionally required. Complete if you have chosen ventilatorassociated pneumonia (VAP) as an event to follow in your Plan for this
month.
For each day of the month, at the same time each day, record the number
of patients on the selected unit who are on a ventilator.
Required. Totals for each column should be calculated. This is the
number that will be entered into the NHSN application.
While not on the paper data collection form, when completing summary
data entry on-line, if no events included on your monthly reporting plan
are reported, you will be required to check the appropriate Report No

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Tables of Instructions

Data Field
Custom Fields

Instructions for Data Collection
Events box(es), i.e., CLABSI, CAUTI, VAP.
Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYY), numeric,
or alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom
Options section of NHSN before the field can be selected for use.

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Table 8. Instructions for Completion of the Denominators for Neonatal
Intensive Care Unit (NICU) (CDC 57.116) (Tables of Instructions List)
Data Field
Facility ID #
Location code
Month
Year
Birthweight Categories

Number of patients (Pts)

Number of patients with a
central line (CL):

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer.
Required. Enter the location code of the unit where you collect the data.
Required. Record the 2-digit month during which the data were
collected for this location.
Required. Record the 4-digit year during which the data were collected
for this location.
Required. The birthweight categories are as follows: A = ≤750 g; B =
751-1000 g; C = 1001-1500 g; D = 1501-2500 g; E = >2500 g. Data on
this form are stratified by this category.
Required. For each day of the month selected, record the number of
patients in each birthweight category on the unit. Record this number at
the same time each day.
Conditionally required. Complete if you have chosen central lineassociated bloodstream infection (CLABSI) as an event to follow in
your Plan for this month for this unit.
For each day of the month, at the same time each day, record the number
of patients in each birthweight category on the selected unit who have 1
or more central line(s) in place.
NOTE: Umbilical catheters are considered central lines.

Number of patients on a
ventilator (VNT)

Number of patients with an
indwelling urinary catheter
(UrC)
Total
Report No Events

Custom Fields

January 2012

Conditionally required. Complete if you have chosen ventilatorassociated pneumonia (VAP) as an event to follow in your Plan for this
unit for this month.
For each day of the month, at the same time each day, record the number
of patients in each birthweight category on the selected unit who are on
a ventilator.
Optional. This field can be completed even though NICU CAUTI
surveillance cannot be included in your plan.
Required. Totals for each column should be calculated. This is the
number that will be entered into the NHSN application.
While not on the paper data collection form, when completing summary
data entry on-line, if no events included on your monthly reporting plan
are reported, you will be required to check the appropriate Report No
Events box(es), i.e., CLABSI, CAUTI, VAP.
Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYY),
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NHSN Patient Safety Component
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Data Field

Instructions for Data Collection
numeric, or alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom
Options section of NHSN before the field can be selected for use.

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See Dialysis Manual for detailed instructions for Dialysis Event (DE) surveillance.

Table 9. Instructions for Completion of Dialysis Event (DE) form (CDC
57.109) see http://www.cdc.gov/nhsn/psc_da.html

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NHSN Patient Safety Component
Tables of Instructions

Table 10. See Instructions for Completion of Denominators for Outpatient
Dialysis: Census Form (CDC 57.119) http://www.cdc.gov/nhsn/psc_da.html

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NHSN Patient Safety Component
Tables of Instructions

Table 11. Instructions for Completion of the AUR Option Forms (CDC
57.123 and CDC 57.124) (Tables of Instructions List)
As of 2010, these forms were retired.
Please refer to Patient Safety Component Manual Chapter 11 for the protocol for collecting and
reporting of Antimicrobial Use Option data, which became available for use in v6.4 (June 2011). Note
that this option does not have a data collection form or manual data entry and instead uses Clinical
Document Architecture (CDA) as the sole means of data reporting. Appendix A gives detailed
instructions of the data field specifications.
The Antimicrobial Resistance Option is currently undergoing revision, and no data may be reported to
NHSN at this time.

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Tables of Instructions

Table 12. Instructions for Completion of the Surgical Site Infection
(SSI) Form (CDC 57.120) (Tables of Instructions List)
Data Field
Facility ID #
Event #
Patient ID #

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by the computer.
Event ID number will be auto-entered by the computer.
Required. Enter the alphanumeric patient ID number. This is the patient
identifier assigned by the hospital and may consist of any combination of
numbers and/or letters.
Social Security #
Optional. Enter the 9-digit numeric patient Social Security Number.
Secondary ID #
Optional. Enter the alphanumeric ID number assigned by the facility.
Medicare #
Optional. Enter the patient’s Medicare number.
Patient name
Optional. Enter the last, first, and middle name of the patient.
Gender
Required. Check Female, Male, or Other to indicate the gender of the patient.
Date of birth
Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Ethnicity
Optional.
Hispanic or Latino If patient is Hispanic or Latino, check this box.
Not Hispanic or Not If patient is not Hispanic or not Latino, check this box.
Latino
Race
Optional.
Check all the boxes that apply to identify the patient’s race.
Event type
Required. Enter SSI.
Date of event
Required. The date when the first clinical evidence of the SSI appeared or the
date the specimen used to make or confirm the diagnosis was collected,
whichever comes first. Enter date of this event using this format:
MM/DD/YYYY.
NHSN procedure
Required. Enter the appropriate NHSN procedure code. For detailed
code
instructions on how to report NHSN operative procedures, see Chapter 9 of
NHSN Patient Safety Component Manual.
NOTE: An SSI cannot be “linked” to an operative procedure unless that
procedure has already been added to NHSN. If the procedure was previously
added, and the “Link to Procedure” button is clicked, the fields pertaining to the
operation will be auto-entered by the computer.
Date of procedure
Required. Enter date using this format: MM/DD/YYYY.
ICD-9-CM procedure Optional. The ICD-9-CM code may be entered here instead of (or in addition
code
to) the NHSN Procedure Code. If the ICD-9-CM code is entered, the NHSN
code will be auto-entered by the computer. If the NHSN code is entered first,
you will have the option to select the appropriate ICD-9-CM code. In either
case, it is optional to select the ICD-9-CM code. The only allowed ICD-9-CM

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Data Field

Outpatient Procedure
MDRO Infection
Surveillance

Location

Date admitted to
facility

Event details
specific event
SSI

January 2012

Instructions for Data Collection
codes are shown in Table 1: NHSN Operative Procedure Category Mappings to
ICD-9-CM Codes in the Surgical Site Infection Event chapter (Chapter 9 of
NHSN Patient Safety Component Manual).
Required. Check Y if this operative procedure was performed on an NHSN
outpatient; otherwise check N.
Required. Enter “Yes”, if the pathogen is being followed for Infection
Surveillance in the MDRO/CDI Module in that location as part of your
Monthly Reporting Plan: MRSA, MSSA (MRSA/MSSA), VRE, CephRKlebsiella, CRE-E. coli, CRE-Klebsiella, MDR-Acinetobacter or C. difficile.
If the pathogen for this infection happens to be an MDRO but your facility is
not following the Infection Surveillance in the MDRO/CDI Module in your
Monthly Reporting Plan, answer “No” to this question.
NOTE: For an SSI, the location of attribution is the post-op location, so if1. The event occurs in a different calendar month from the surgical
procedure AND
2. Your facility is performing Infection Surveillance for the organism
causing the SSI in the post-op location for the month reported in the
Date of Event,
Then please answer “Yes” to this question.
Conditionally required if MDRO Infection Surveillance field is Yes. Enter the
patient care area where the patient was assigned in the postoperative period.
Inpatient or outpatient locations are allowed, but Operating Room locations are
not allowed.
Required. Enter date patient admitted to facility using this format:
MM/DD/YYYY. If a patient is readmitted with a previously unreported SSI
associated with an operative procedure performed during a previous admission,
enter the date of admission of the facility stay in which the operative procedure
was performed. An NHSN Inpatient is defined as a patient whose date of
admission to the healthcare facility and the date of discharge are different calendar
days. When determining a patient’s admission dates to both the facility and
specific inpatient location, the NHSN user must take into account all such days,
including any days spent in an inpatient location as an “observation” patient
before being officially admitted as an inpatient to the facility, as these days
contribute to exposure risk. Therefore, all such days are included in the counts
of admissions and patient days for the facility and specific location, and facility
and admission dates must be moved back to the first day spent in the inpatient
location.
Required. Check the appropriate level of SSI from the list
___Superficial incisional primary (SIP)
___Superficial incisional secondary (SIS)
___Deep incisional primary (DIP)
___Deep incisional secondary (DIS)
___ Organ/space: __ (Indicate specific site code from Table 2. Specific Sites of

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Data Field

Event details: SSI
Specify criteria used

Event details:
Detected

Event Details:
Secondary
bloodstream infection
Event details:
Died
Event Details:
SSI contributed to
death
Event Details:
Discharge date

Event Details:
Pathogens identified
Custom Fields

Comments

January 2012

Instructions for Data Collection
Organ/Space SSI in the Surgical Site Infection Event chapter [Chapter 9] of
NHSN Patient Safety Component Manual.)
Required. Check each of the elements of the definition that were used to
identify the specific type of SSI. Specific Organ/space event types have their
own unique criteria which must be met. They are found in Chapter 17 of the
Patient Safety Component Manual: CDC/NHSN Surveillance Definition of
Healthcare-Associated Infection and Criteria for Specific Types of Infections in
the Acute Care Setting.
Required.
Check A if SSI was identified before the patient was discharged from the
facility following the operation.
Check P if SSI was identified during post-discharge surveillance. Include as P
those SSI identified in the Emergency Department but not readmitted to the
facility.
Check RF if SSI was identified due to patient readmission to the facility where
the operation was performed.
Check RO if SSI was identified due to readmission to facility other than where
the operation was performed.
Required. Check Y if there is a culture-confirmed bloodstream infection (BSI)
and a related healthcare-associated infection at the surgical site, otherwise
check N.
Required. Check Y if patient died during the hospitalization, otherwise check
N.
Conditionally required. If patient died, check Y if the SSI contributed to death,
otherwise check N.
Optional. Enter date patient discharged from facility using this format:
MM/DD/YYYY. If a patient is readmitted with a previously unreported SSI
associated with an operative procedure performed in a previous admission,
enter the date of discharge of the facility stay in which the operative procedure
was performed.
Required. This field will be auto entered by the computer as Y. Specify
pathogens on reverse of form (see Table 2a above for instructions).
Optional. Up to 50 fields may be customized for local or group use in any
combination of the following formats: date (MMDDYYY), numeric, or
alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom Options
section of the application before the field can be selected for use.
Optional. Enter any information on the event.

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Table 13. Instructions for Completion of the Denominator for Procedure
form (CDC 57.121) (Tables of Instructions List)
This form is used for reporting data on each patient having one of the NHSN operative procedures
selected for monitoring.
Data Field
Facility ID #
Procedure #
Patient ID #

Social Security #
Secondary ID #
Medicare #
Patient name
Gender
Date of birth
Ethnicity

Instructions for Data Collection
The NHSN-assigned facility ID will be auto-entered by
the computer.
The NHSN-assigned Procedure # will be auto-entered by
the computer
Required. Enter the alphanumeric patient ID number.
This is the patient identifier assigned by the hospital and
may consist of any combination of numbers and/or
letters.
Optional. Enter the 9-digit numeric patient Social
Security Number.
Optional. Enter the alphanumeric ID number assigned
by the facility.
Optional. Enter the patient’s Medicare number.

Optional. Enter the last, first, and middle name of the
patient.
Required. Check Female, Male, or Other to indicate the
gender of the patient.
Required. Record the date of the patient birth using this
format: MM/DD/YYYY.
Optional.
Hispanic or Latino If patient is Hispanic or Latino, check this box.

Not Hispanic or Not Latino If patient is not Hispanic or not Latino, check this box.
Race
Optional.
Check all the boxes that apply to identify the patient’s
race.
Event type
Required. Enter the code for procedure (PROC).
NHSN Procedure code
ICD-9-CM procedure code

Required. Enter the appropriate NHSN procedure code.
Optional. The ICD-9-CM code may be entered here
instead of (or in addition to) the NHSN Procedure Code.
If the ICD-9-CM code is entered, the NHSN code will be
auto-entered by the computer. If the NHSN code is
entered first, you will have the option to select the

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Data Field

Date of procedure

Instructions for Data Collection
appropriate ICD-9-CM code. In either case, it is optional
to select the ICD-9-CM code. The only allowed ICD-9CM codes are listed in Table 1: NHSN Operative
Procedure Category Mappings to ICD-9-CM Codes in
the Surgical Site Infection Event chapter (Chapter 9 of
NHSN Patient Safety Component Manual).
Required. Record the date when the NHSN procedure
was done using this format: MM/DD/YYYY.

Procedure Details:
Outpatient: Required. Check Y if this operative procedure was
performed on an NHSN outpatient, otherwise check N.
Duration: Required. Enter the interval in hours and minutes
between the skin incision and skin closure.
Wound class: Required. Check the appropriate wound class from the
list.
General anesthesia: Required. Check Y if general anesthesia was used for the
operative procedure, otherwise check N. General
anesthesia is defined as the administration of drugs or
gases that enter the general circulation and affect the
central nervous system to render the patient pain free,
amnesic, unconscious, and often paralyzed with relaxed
muscles.
ASA class: Conditionally Required. Required for Inpatient
procedures only. Check numeric ASA classification at
the time of the operative procedure.
Emergency: Required. Check Y if this operative procedure was a
nonelective, unscheduled operative procedure, otherwise
check N. Emergency operative procedures are those that
do not allow for the standard immediate preoperative
preparation normally done within the facility for a
scheduled operation (e.g., stable vital signs, adequate
antiseptic skin preparation, colon decontamination in
advance of colon surgery, etc.).
Trauma: Required. Check Y if operative procedure was
performed because of blunt or penetrating traumatic
injury to the patient, otherwise check N.

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Data Field

Instructions for Data Collection
Endoscope: Required. Check Y if the entire operative procedure was
performed using an endoscope/laparoscope/robotic assist.
Check N if the endoscope incision was extended to allow
hand assistance, or was fully converted to an open
approach.
NOTE: For CBGB, if the donor vessel was harvested
using an endoscope, check Y.
Surgeon code: Optional. Enter code of the surgeon who performed the
principal operative procedure.
Implant: Required. Check Y if a nonhuman-derived object,
material, or tissue was permanently placed in a patient
during the operative procedure and will not be routinely
manipulated for diagnostic or therapeutic purposes (see
“Implant” key terms for example), otherwise check N.

CSEC: Height

CSEC: Weight

CSEC: Duration of labor

Circle one: FUSN RFUSN
FUSN/RFUSN: Spinal level

January 2012

Conditionally required. If operative procedure is CSEC,
enter patient height in feet and inches or meters and
centimeters.
Conditionally required. If operative procedure is CSEC,
enter patient’s most recent weight in pounds or
kilograms.
Conditionally required. If operative procedure is CSEC,
enter number of hours the patient labored in the hospital
from beginning of active labor to delivery of the infant,
expressed in hours. The documentation of active labor
can be supplied in the chart by a member of the
healthcare team or physician. Active labor may be
defined by the individual facility’s policies and
procedures.
If a patient is admitted for a scheduled CSEC and has not
yet gone into labor, the duration of labor would be 0.
Hours should be rounded in the following manner: ≤ 30
minutes round down; > 30 minutes round up.
Conditionally required. If operative procedure is FUSN
or RFUSN, circle the procedure that was done.
Conditionally required. If operative procedure is FUSN
or RFUSN, check appropriate spinal level of procedure
from list.
•
Atlas-Axis – C1 and/or C2 only
•
Atlas-Axis/Cervical – C1-C7 (any combination

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Data Field

FUSN/RFUSN: Diabetes mellitus

FUSN/RFUSN: Approach/Technique

HPRO:

KPRO:

Custom Fields

Instructions for Data Collection
excluding C1 and/or C2 only)
•
Cervical – C3-C7 (any combination)
•
Cervical/Dorsal/Dorsolumbar – Extends from any
cervical through any lumbar levels
•
Dorsal/Dorsolumbar – T1 – L5 (any combination
of thoracic and lumbar)
•
Lumbar/Lumbosacral – L1-S5 (any combination
of lumbar and sacral)
•
Not specified – Level not specified (should be
used rarely)
If not specified, record will not be included in SIR
calculations.
Conditionally required. If operative procedure is FUSN
or RFUSN, check Y if patient is known to have diabetes
mellitus, otherwise check N.
Conditionally required. If operative procedure is FUSN
or RFUSN, check appropriate surgical approach or
technique from list.
Conditionally required. If operative procedure is HPRO,
select TP (Total Primary), PP (Partial Primary), TR
(Total Revision) or PR (Partial Revision) from the list.
NOTE: When hardware is inserted for the first time, use
the “primary” designation; otherwise, indicate that the
procedure was a revision.
Conditionally required. If operative procedure is KPRO,
select T – Primary (Total), R – Revision (Total or Partial)
from list.
NOTE: When hardware is inserted for the first time, use
the “primary” designation; otherwise, indicate that the
procedure was a revision.
Optional. Up to 50 fields may be customized for local or
group use in any combination of the following formats:
date (MMDDYYY), numeric, or alphanumeric.
NOTE: Each Custom Field must be set up in the
Facility/Custom Options section of NHSN before the
field can be selected for use. Data in these fields may be
analyzed.

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Table 14. Instructions for Completion of the Vaccination Monthly
Monitoring Form – Summary Method (57.130) (Tables of Instructions List)
Data Field

Instructions for Data Collection

Facility ID #

The NHSN-assigned facility ID number will be auto-entered by the computer.

Vaccination type
Influenza subtype

Required; defaulted to “Influenza” by the computer.
Required. Check one: □ Seasonal □ Non-seasonal

Month

Required. Record using this format: MM

Year

Required. Record using this format: YYYY

1. Total # of patient admissions

Required. The count of NHSN inpatients admitted to the facility during the
month being monitored.
Required. The count of NHSN inpatients meeting criteria for vaccination.
Include in this count any patients who have been previously vaccinated during
the current influenza season.
Optional. The count of NHSN inpatients who had previously received influenza
vaccination during the current influenza season by either history or
documentation. Patients requiring a second vaccine should not be included in the
count of those previously vaccinated.
Required. The difference in the count of NHSN inpatients meeting criteria for
influenza vaccination (Box 2) minus the count of NHSN inpatients who had been
previously vaccinated during the current influenza season (Box 3). This number
will be auto-entered by the computer.
Required. The count of NHSN inpatients meeting criteria for influenza
vaccination who were offered vaccination but who declined for reasons other
than medical contraindication(s).

2. Total # of patients aged 6 months
and older meeting criteria for
influenza vaccination
3. Total # of patients previously
vaccinated during current influenza
season
4. Total patients not previously
vaccinated during current influenza
season (Box 2 - Box 3)
5. Patients meeting criteria offered
vaccination but declining for
reasons other than medical
contraindication
6. Patients meeting criteria offered
vaccination but having medical
contraindication
7. Patients meeting criteria
receiving vaccination during
admission

Required. The count of NHSN inpatients meeting criteria for influenza
vaccination who were offered vaccination but who declined because of medical
contraindication(s).
Required. The count of NHSN inpatients meeting criteria for influenza
vaccination who had documentation in the medical record of receiving influenza
vaccination during the course of their hospital admission prior to being
discharged.
8. Total patients offered vaccination Required. The sum of the count of NHSN inpatients who were offered influenza
(Box 5 + Box 6 + Box 7)
vaccination but who declined for reasons other than medical contraindication(s)
(Box 5) plus those offered vaccination but declined because of medical
contraindication(s) (Box 6) plus those with documentation in the medical record
of receiving vaccination during the course of their hospital admission (Box 7).
The number in this box should be less than or equal to the number in Box 4. This
number will be auto-entered by the computer.
Custom Fields
Optional. Up to 50 fields may be customized for local or group use in any

combination of the following formats: date (MMDDYYY), numeric, or
alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom Options
section of NHSN before the field can be selected for use. Data in these fields

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Data Field

Instructions for Data Collection
may be analyzed.

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Table 15. Instructions for Completion of the Vaccination Monthly
Monitoring Form – Patient-Level Method (CDC 57.131) (Tables of Instructions
List)

Data Field
Facility ID #
Vaccination type

Instructions for Data Collection
The NHSN-assigned facility ID number will be auto-entered by the
computer.
Required; defaulted to “ Influenza” by the computer.

Influenza subtype

Required. Check one: □Seasonal □Non-seasonal

Month
Required. Record using this format: MM
Year
Required. Record using this format: YYYY
1. Total # of patient admissions Required. The count of NHSN inpatients admitted to the facility
during the month being monitored.
2. Total # of patients aged 6
Required. The count of NHSN inpatients meeting criteria for
months and older meeting
vaccination. Include in this count any patients who have been
criteria for influenza vaccination previously vaccinated during the current influenza season.
3. Total # of patients previously Optional. The count of NHSN inpatients who had previously
vaccinated during current
received influenza vaccination during the current influenza season
influenza season
by either history or documentation. Patients requiring a second
vaccine should not be included in the count of those previously
vaccinated.
4. Total patients not previously Required. The difference in the count of NHSN inpatients meeting
vaccinated during current
criteria for influenza vaccination (Box 2) minus the count of NHSN
influenza season (Box 2 - Box 3) inpatients who had been previously vaccinated during the current
influenza season (Box 3). This number will be auto-entered by the
computer.
Custom Fields
Optional. Up to 50 fields may be customized for local or group use
in any combination of the following formats: date (MMDDYYY),
numeric, or alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom
Options section of NHSN before the field can be selected for use.
Data in these fields may be analyzed.

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Table 16. (Form has been retired and is no longer used.)
(Tables of Instructions List)

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Table 17. Instructions for Completion of the Patient Vaccination Form
(CDC 57.133)
(Tables of Instructions List)

Data Field
Facility ID #
Event #
Patient ID

Social Security #
Secondary ID
Medicare #
Patient name
Gender

Instructions for Data Collection
The NHSN-assigned facility ID number will be auto-entered by the
computer.
Event ID number will be auto-entered by the computer.
Required. Enter the alphanumeric patient ID number. This is the
patient identifier assigned by the hospital and may consist of any
combination of numbers and/or letters.
Optional. Enter the 9-digit numeric patient Social Security Number.
Optional. Enter the alphanumeric ID number assigned by the facility.
Optional. Enter the patient’s Medicare number.
Optional. Enter the last, first, and middle name of the patient.

Event Type

Required. Circle F (female), M (male) or Other to indicate the gender
of the patient.
Required. Record the date of the patient birth using this format:
MM/DD/YYYY
Optional. Indicate the patient’s ethnicity:
Hispanic or Latino
Not Hispanic or Not Latino
Optional. Indicate the patient’s race (all that apply):
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Required. FLUVAX.

Influenza subtype

Required. Check one: □Seasonal □Non-seasonal.

Vaccine offered

Required. Check Yes or No.

Vaccine declined

Required. Check Yes or No.

Reason(s) vaccine declined
A. Medical
contraindication(s)
B. Personal reason(s) for

Conditionally required. If patient declined influenza vaccination,
check all that apply in either section A or section B, but not both. If
reasons exist in both categories then section A, medical
contraindications, takes priority and should be completed.

Date of Birth
Ethnicity

Race

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Data Field
declining
Vaccine administered
Date vaccine administered
Type of influenza vaccine
administered
Seasonal or Non-seasonal

Manufacturer

Lot number
Route of administration
Vaccine Information
Statement Provided to Patient
Person administering vaccine:
Vaccinator ID

Instructions for Data Collection
Required. Check Yes or No.
Conditionally required. If vaccine administered, indicate date given
using this format: MM/DD/YYYY
Conditionally required. If vaccine administered, indicate which
vaccine (seasonal or non-seasonal) and whether it was a live
attenuated vaccine (LAIV) or inactivated vaccine (TIV) formulation.
If both seasonal and non-seasonal vaccines are administered to a
patient, complete a separate Patient Vaccination form for each.
Conditionally required. If vaccine administered, influenza vaccine
manufacturer will be auto-entered by computer when vaccine type is
selected.
Conditionally required. If vaccine administered, enter the lot number
of the vaccine given to the patient.
Conditionally required. If vaccine administered, indicate the route of
administration used.
Optional. If vaccine administered, indicate what type of information
statement was provided, if any, and the edition date using this format:
MM/DD/YYYY; otherwise, check “None or unknown”.
Optional. If vaccine administered, indicate vaccinator identifier. This
is an identifier assigned by the facility and may consist of any
combination of numbers and/or letters.
Optional. If vaccine administered, indicate title of vaccinator (RN,
LPN, Nurse Assistant, etc.).
Optional. If vaccine administered, indicate name of vaccinator by last
name, first name, middle name or initial.
Optional. This information will be auto-entered by the computer.

Person administering vaccine:
Title
Person administering vaccine:
Name
Person administering vaccine:
Work address, City, State, Zip
code
Custom Fields
Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYY),
numeric, or alphanumeric.

Comments

January 2012

NOTE: Each Custom Field must be set up in the Facility/Custom
Options section of NHSN before the field can be selected for use. Data
in these fields may be analyzed.
Optional. Enter comments about this vaccination. Data in this field
cannot be analyzed.

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Table 18. Instructions for Completion of the Influenza Vaccination
Standing Orders Form - Optional (CDC 57.134) (Tables of Instructions List)
Data Field
Facility ID

Instructions for Data Collection
Required. Blank space for facility to place identification information of
the facility as indicated or required by the facility.
Patient identifiers
Required. Blank space for facility to place patient identification label or
stamp as indicated. Minimum information required includes the
alphanumeric patient ID (i.e., the patient identifier assigned by the
hospital and may consist of any combination of numbers and/or letters),
gender, and date of birth.
DO NOT VACCINATE
Optional. Check one of the choices.
Vaccine offered
Required. Check Yes or No.
Influenza Subtype
Conditionally required. Check Seasonal or Non-seasonal.
Vaccine declined
Required. Check Yes or No.
Reason(s) vaccine declined Conditionally required. If patient declined influenza vaccination, check
all that apply in either section A or section B, but not both. If reasons
exist in both categories then section A, medical contraindications, takes
priority and should be completed.
Orders
Required. Check Vaccinate; Do NOT Vaccinate; or Standing Order –
no signature required.
Physician signature
Conditionally required. Signature of ordering physician is required if
standing order policy is not in place and checked.
Vaccine administered
Required. Check Yes or No.
Date administered
Conditionally required. If vaccine administered, enter date in
MM/DD/YYYY format.
Type of influenza vaccine
Conditionally required. If vaccine administered, indicate which specific
administered: Seasonal or
vaccine of the seasonal or non-seasonal type was given, and whether it
Non-seasonal
was a live attenuated vaccine (LAIV) or inactivated vaccine (TIV)
formulation.
Manufacturer
Conditionally required. If vaccine administered, enter name of
manufacturer.
Lot number
Conditionally required. If vaccine administered, enter lot number used.
Route of administration
Conditionally required. If vaccine administered, indicate route of
administration used.
Vaccine information
Optional. If vaccine administered, indicate type and edition date of
statement (VIS) provided to vaccine information statement provided, if no vaccine information
patient
statement was provided (None), or if it is unknown.
Vaccinator ID and Title of Optional. If vaccine administered, indicate vaccinator identifier. This is
Person Administering
an identifier assigned by the facility and may consist of any

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Data Field

Instructions for Data Collection
Vaccine
combination of numbers and/or letters. Indicate the title of the
vaccinator (RN, LPN, Nurse Assistant, etc.).
Name
Optional. If vaccine administered, indicate name of vaccinator by last
name, first name, middle name or initial.
Work Address, City, State, Optional. If vaccine administered, indicate work address of vaccinator.
Zip code
Typically, this would be the facility’s address.

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Table 19. Instructions for Completion of the Laboratory-identified
MDRO or CDI Event form (CDC 57.128) (Tables of Instructions List)
Data Field
Facility ID

Social Security #
Secondary ID

Instructions for Form Completion
The NHSN-assigned facility ID number will be auto-entered by the
computer.
Event ID number will be auto-entered by the computer.
Required. Enter the alphanumeric patient ID. This is the patient identifier
assigned by the hospital and may consist of any combination of numbers
and/or letters. This should be an ID that remains the same for the patient
across all visits and admissions.
Optional. Enter the 9-digit numeric patient Social Security Number.
Optional. Enter any other patient ID assigned by the facility.

Medicare #

Optional. Enter the patient’s Medicare number.

Patient Name, Last
First, Middle
Gender

Optional. Enter the name of the patient. If available, data will be autoentered from Patient Form.
Required. Circle M (Male), F (Female) or Other to indicate the gender of the
patient.
Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Optional. Enter the patient’s ethnicity:
Hispanic or Latino
Not Hispanic or Not Latino
Optional. Enter the patient’s race: Select all that apply.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Event Details
Required. Event type = LabID.

Event #
Patient ID

Date of Birth
Ethnicity (specify)

Race (specify)

Event Type

Date Specimen Collected Required. Enter the date the specimen was collected for this event using
format: MM/DD/YYYY
Specific Organism Type Required. Check the pathogen identified for this specimen from one of the
following laboratory-identified organism types: MRSA, MSSA (if tracking
MRSA & MSSA), VRE, CephR-Klebsiella, CRE-E. coli, CRE-Klebsiella,
MDR-Acinetobacter or C. difficile. Use one form per LabID event (i.e., 1
form for each pathogen).
Outpatient
Required. Select “Yes” if the LabID Event is being reported from an
outpatient location where there are no admissions (e.g., emergency
department, wound care clinic, etc.). If the patient was an outpatient, Date
Admitted to Facility and Date Admitted to Location are not required.
Specimen Body Site
Required. Enter the main body site from which the specimen was taken
using the description that is most specific. (e.g., digestive system, central

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Data Field

Instructions for Form Completion
nervous system, etc.)

Specimen Source

Required. Enter the specific anatomic site from which the specimen was
taken using the source description that is most accurate from the available
choices (e.g., bile specimen, specimen from brain, etc.)
Date Admitted to Facility Conditionally required. Enter the date the patient was admitted to facility
using this format: MM/DD/YYYY. If the LabID Event was reported from
an outpatient location, leave this blank. An NHSN Inpatient is defined as
a patient whose date of admission to the healthcare facility and the date of
discharge are different calendar days. When determining a patient’s

admission dates to both the facility and specific inpatient location, the
NHSN user must take into account all such days, including any days
spent in an inpatient location as an “observation” patient before being
officially admitted as an inpatient to the facility, as these days
contribute to exposure risk. Therefore, all such days are included in
the counts of admissions and patient days for the facility and specific
location, and facility and admission dates must be moved back to the
first day spent in the inpatient location.
Location

Date Admitted to
Location

Conditionally required. Enter the patient care area where the patient was
assigned when the laboratory-identified MDRO or C. difficile event
specimen was collected (i.e., the NHSN “transfer rule” does not apply for
LabID events). Special Case: If a specimen collected in the emergency
department is positive for an MDRO or CDI, and the patient it is collected
from is admitted to the facility on the SAME date into a location that is
monitoring LabID Events for the identified MDRO or CDI, then that
specimen can be reported as the first specimen for the patient in that
admitting inpatient location for the month. If the facility is also monitoring
LabID Events for the same MDRO or CDI in the emergency department,
then the same specimen for the patient would also be reported a second time
for that outpatient location.
Conditionally required. Enter the date the patient was admitted to the patient
care area where laboratory-identified monitoring is being performed and
where the specimen was collected from the patient. Any days spent in an

inpatient location, whether as an officially admitted patient or as an
“observation” patient, contribute to exposure risk. An NHSN
Inpatient is defined as a patient whose date of admission to the
healthcare facility and the date of discharge are different calendar days.
Therefore, all such days are included in the counts of patient days for
the facility and specific location. Special Emergency Department Cases:

Documented prior
evidence of infection or
colonization with this
specific organism type

January 2012

Note that because of existing business rules for edit checks in NHSN, the
date of specimen collection must be the same date or later than the admission
date.
Non-editable. “Yes” or “No” will be auto-filled by the system only,
depending on whether there is prior LabID Event entered for the same
organism and same patient. Cannot be edited by user. If there is a previous
LabID event for this organism type entered in NHSN in a prior month, the

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Data Field
from a previously
reported LabID Event?
Has patient been
discharged from your
facility in the past 3
months?
Date of last discharge
from your facility

Instructions for Form Completion
system will auto-populate with a “Yes.”

Custom Fields

Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYY),
numeric, or alphanumeric.

Comments

January 2012

Required. Circle “Yes” if the patient has been an inpatient and discharged
from your facility in the past three months, otherwise circle “No”.

Conditionally Required. If the patient was discharged from your facility in
the past 3 months (previous question is circled “Yes”), enter the most recent
date of discharge prior to the current admission. Use format:
MM/DD/YYYY
Custom Fields

NOTE: Each Custom Field must be set up in the Facility/Custom Options
section of the application before the field can be selected for use.
Optional. Enter any information on the Event. This information may not be
analyzed.

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Table 20. Instructions for Completion of the MDRO or CDI Infection
Event form (CDC 57.126) (Tables of Instructions List)
Data Field
Facility ID

Instructions for Form Completion
The NHSN-assigned facility ID number will be auto-entered by the computer

Event #

Event ID number will be auto-entered by the computer

Patient ID

Social Security #

Required. Enter the alphanumeric patient ID. This is the patient identifier
assigned by the hospital and may consist of any combination of numbers
and/or letters. This should be an ID that remains the same for the patient
across all visits and admissions.
Optional. Enter the 9-digit numeric patient Social Security Number.

Secondary ID

Optional. Enter any other patient ID assigned by the facility.

Medicare #

Optional. Enter the patient’s Medicare number.

Patient Name, Last
First
Middle
Gender

Optional. Enter the name of the patient.

Date of Birth

Required. Record the date of the patient birth using this format:
MM/DD/YYYY.
Optional. Enter the patient’s ethnicity:
Hispanic or Latino
Not Hispanic or Not Latino
Optional. Enter the patient’s race: (select all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Event Details

Ethnicity (specify)

Race (specify)

Event Type

Date of Event

Post Procedure Event
Date of Procedure
MDRO Infection

January 2012

Required. Circle M (Male), F (Female) or Other to indicate the gender of the
patient.

Required. Enter infection event type other than BSI, DE, Pneumonia, SSI, or
UTI. For reporting MDRO infections that are BSI, Pneumonia, SSI, or UTI,
use those infection forms and instructions.
Required. Enter the date the first clinical symptoms of infection occurred or
the date the first positive specimen was collected, whichever came first. Use
format: MM/DD/YYYY.
Required. Circle “Yes” if the infection occurred after an NHSN-defined
procedure but before discharge from the facility, otherwise circle “No”.
Conditionally required. If an NHSN-defined procedure was performed, enter
date using this format: MM/DD/YYYY.

Required. Enter “Yes”, if the pathogen is being followed for Infection
Surveillance in the MDRO/CDI Module in that location as part of your
Monthly Reporting Plan: MRSA, MSSA (MRSA/MSSA), VRE,
CephR-Klebsiella, CRE-E. coli, CRE-Klebsiella, MDR-Acinetobacter
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Data Field

Instructions for Form Completion

or C. difficile.
If the pathogen for this infection happens to be an MDRO but your
facility is not following the Infection Surveillance in the MDRO/CDI
Module in your Monthly Reporting Plan, answer “No” to this question.
NHSN Procedure code

Conditionally required. Answer this question only if this patient developed the
MDRO or C. difficile infection during the same admission as an operative
procedure. Enter the appropriate NHSN procedure code. NOTE: An MDRO
infection cannot be “linked” to an operative procedure unless that procedure
has already been added to NHSN. If the procedure was previously added, and
the “Link to Procedure” button is clicked, the fields pertaining to the operation
will be auto-entered by the computer.
ICD-9-CM Procedure Code Optional. The ICD-9-CM code may be entered here instead of (or in addition
to) the NHSN Procedure Code. If the ICD-9-CM code is entered, the NHSN
code will be auto-entered by the computer. If the NHSN code is entered first,
you will have the option to select the appropriate ICD-9-CM code. In either
case, it is optional to select the ICD-9-CM code.
Specific Organism Type
Required. Check the pathogen(s) identified for this infection event. You may
select up to 3.
Date Admitted to Facility Required. Enter date patient admitted to facility using this format:
MM/DD/YYYY. An NHSN Inpatient is defined as a patient whose date of
admission to the healthcare facility and the date of discharge are different
calendar days. When determining a patient’s admission dates to both the

facility and specific inpatient location, the NHSN user must take into
account all such days, including any days spent in an inpatient location
as an “observation” patient before being officially admitted as an
inpatient to the facility, as these days contribute to exposure risk.
Therefore, all such days are included in the counts of admissions and
patient days for the facility and specific location, and facility and
admission dates must be moved back to the first day spent in the
inpatient location.
Location

Required. Enter the nursing care area where the patient was assigned when the
MDRO or C. difficile infection (CDI) was acquired. If the MDRO or CDI
developed in a patient within 48 hours of discharge from a location, indicate
the discharging location, not the current location of the patient.
Specific Event Type
Required. List the specific CDC-defined infection event type. For event type =
BSI, PNEU, SSI or UTI this form should not be used. Use the form designed
for that event.
Signs & Symptoms
Required. Using the criteria in Table 17, check all signs and symptoms used to
confirm the diagnosis of this infection event in the observed patient.
Laboratory or Diagnostic Conditionally required. Indicate whether any blood cultures, other laboratory
Testing
tests or radiologic exams were used to diagnose the infection.
Clostridium difficile Infection
Admitted to ICU for CDI
complications

January 2012

Conditionally required. If pathogen is C. difficile, circle “Yes” to indicate
admission to ICU for C. difficile complications (e.g., shock that requires
vasopressor therapy), otherwise circle “No”.

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Data Field
Surgery for CDI
complications

Instructions for Form Completion
Conditionally required. If pathogen is C. difficile, circle “Yes” to indicate
surgery for C. difficile complications, otherwise circle “No”. Surgery might
include colectomy for toxic megacolon, perforation or refractory colitis.
Secondary Bloodstream
Required. Circle “Yes” if there is a culture-confirmed bloodstream infection
Infection
(BSI) during this admission, secondary to this infection, for the same pathogen.
Otherwise circle “No”.
Died
Required. Circle “Yes” if the patient died during this hospitalization, otherwise
circle “No”.
Event Contributed to Death Conditionally Required.
MDRO: If the patient died during this admission, circle “Yes” if the MDRO
infection contributed to death, otherwise circle “No”.

Discharge Date

Pathogens Identified

CDI: Circle “Yes” only if the patient died within 30 days after C. difficile
infection symptom onset and during the current hospital admission.
Optional. Enter the date the patient was discharged from the facility using this
format: MM/DD/YYYY. If the patient died during this admission enter the
death date.
Required. Circle “Yes” if pathogen identified, “No” if otherwise; if “Yes”
indicates the pathogen identified on the antibiogram on page 2. If the pathogen
was C. difficile, enter it under Other Organisms but do not include
antibiogram.
NOTE: Any infection reported as an MDRO or CDI must have a pathogen
identified.

Custom Fields

Comments

January 2012

Optional. Up to 50 fields may be customized for local or group use in
any combination of the following formats: date (MMDDYYY),
numeric, or alphanumeric.
NOTE: Each custom Field must be set up in the Facility/Custom Options
section of the application before the field can be selected for use.
Optional. Enter comments for local use and the values entered. These fields
may not be analyzed.

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Table 21. Instructions for Completion of the MDRO and CDI
Prevention Process and Outcome Measures Monthly Monitoring form
(CDC 57.127) (Tables of Instructions List)
Data Field
Facility ID #
Month
Year
Location Code
Total Patient Days

Total Admissions

Total Encounters

Patient Days

Admissions

January 2012

Instructions for Form Completion
The NHSN-assigned facility ID number will be auto-entered by the
computer
Required. Enter the 2-digit month during which surveillance was
performed.
Required. Enter the 4-digit year during which surveillance was performed.
Required. Enter the code of the patient care location where the outcome
measures monitoring was done.
Conditionally Required. If this is a single inpatient location, enter the total
number of patient days for this location for the month. If this is for
FacWideIN location code, enter the total number of patient days for all
facility inpatient locations combined for the month. All of the facility’s
inpatient locations with an overnight stay should be included, where
denominators can be accurately collected and there is the possibility of the
MDRO to be present, transmitted, and identified in that specific location.
For further information on counting patient days, go to
http://www.cdc.gov/nhsn/PDFs/PatientDay_SumData_Guide.pdf.
Conditionally required. If this is a single inpatient location, enter the total
number of admissions for this location for the month. If this is for
FacWideIN location code, enter the total number of admissions for all
facility inpatient locations combined for the month. All of the facility’s
inpatient locations with an overnight stay should be included, where
denominators can be accurately collected and there is the possibility of the
MDRO to be present, transmitted, and identified in that specific location.
For further information on counting admissions, go to
http://www.cdc.gov/nhsn/PDFs/PatientDay_SumData_Guide.pdf.
Conditionally required. If this is for LabID Event monitoring being
performed in a single outpatient and/or emergency room location, enter the
total number of patient visits/encounters for the location for the month. If
this is for LabID Event monitoring being performed at the FacWideOUT
level, enter the total number of patient visits/encounters for all facility
outpatient locations combined for the month.

Conditionally Required. If LabID C. difficile Events are being
monitored at the FacWideIN level, then Total Patient Days (as
calculated from guidance above) minus any patient days for NICU
or Well Baby Nurseries must be entered here.
Conditionally Required. If LabID C. difficile Events are being
monitored at the FacWideIN level, then Total Admissions (as
calculated from guidance above) minus any admissions for NICU or
Well Baby Nurseries must be entered here.

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Data Field

Encounters

Instructions for Form Completion

Conditionally Required. If LabID C. difficile Events are being
monitored at the FacWideOUT level, then Total Encounters (as
calculated from guidance above) minus any encounters for Well
Baby Clinics must be entered here.
MDRO and CDI Infection Surveillance or LabID Event Reporting

Infection Surveillance

LabID Event
(All specimens)

LabID Event
(Blood specimens only)

Hand Hygiene
Performed

Indicated

Gown and Gloves
Used

Indicated

Conditionally required. Selections for Infection Surveillance will be autofilled if included in the Monthly Reporting Plan. Otherwise, select any
MDRO or C. difficile organism for monitoring Infection Surveillance “offplan” in the location during the time period specified.
Conditionally required. Selections for LabID Event reporting of All
specimens will be auto-filled if included in the Monthly Reporting Plan.
Otherwise, select any MDRO or C. difficile organism for monitoring
LabID Events for All specimens “off-plan” in the location during the time
period specified.
Conditionally required. Selections for LabID Event reporting of Blood
specimens only will be auto-filled if included in the Monthly Reporting
Plan. Otherwise, select any MDRO for monitoring LabID Events for
Blood specimens only “off-plan” at the facility-wide level during the time
period specified.
Process Measures (Optional)
Required for hand hygiene adherence process measures. Enter the total
number of observed contacts during which an HCW touched either the
patient or inanimate objects in the immediate vicinity of the patient and
appropriate hand hygiene was performed (i.e., Hand Hygiene Performed).
Required for hand hygiene adherence process measures. Enter the total
number of observed contacts during which an HCW touched either the
patient or inanimate objects in the immediate vicinity of the patient and
therefore, appropriate hand hygiene was indicated (i.e., Hand Hygiene
Indicated).
Required for gown and gloves use adherence process measures.
Among patients on Contact Precautions, enter the total number of
observed contacts between an HCW and a patient or inanimate objects in
the immediate vicinity of the patient for which gloves and gowns had been
donned prior to the contact (i.e., Gown and Gloves Used).
Required for gown and gloves use adherence process measures.
Among patients on Contact Precautions, enter the total number of
observed contacts between an HCW and a patient or inanimate objects in
the immediate vicinity of the patient and therefore, gloves and gowns were
indicated (i.e., Gown and Gloves Indicated).

Active Surveillance Testing (For MRSA & VRE only)
Active Surveillance Testing Required for active surveillance testing adherence process measures. For
performed
MRSA and VRE only. Selections for AST Performed will be auto-filled if
included in the Monthly Reporting Plan. Otherwise, select either MRSA

January 2012

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Data Field

Timing of AST

Instructions for Form Completion
or VRE for which active surveillance testing is being done “off-plan”
during the time period specified.
Required for active surveillance testing adherence process measures.

•

Adm

Choose the time period when surveillance testing will be performed.

•

Both

Specimens for AST can be obtained at the time of admission (Adm), or at
the time of admission and for patients’ stays of > 3 days, at the time of
discharge/transfer (Both).
Required for admission surveillance testing adherence process measures.

AST Eligible Patients
•

All

If all admitted patients were tested choose All.

•

NHx

Circle NHx if performing AST only on those patients admitted to the
patient care location with no documentation at the time of admission of
MRSA and/or VRE colonization or infection in ≤ 12 months (NHx). That
is, no specimen positive for MRSA and/or VRE for this patient during
previous stays at this facility or from information provided by referring
facilities in ≤ 12 months.
Required for admission surveillance testing adherence process measures.

Admission AST
•

Performed

•

Eligible

•

Performed

•

Eligible

Enter the number of patients eligible for admission AST and who had a
specimen obtained for testing ≤ 3 days of admission (i.e., Admission AST
Performed).

Enter the number of patients eligible for admission surveillance testing.
(i.e., Admission AST Eligible)
Discharge/Transfer AST Required for discharge/transfer active surveillance testing adherence
process measures.
For patients’ stays > 3 days, enter the number of discharged or transferred
patients eligible for AST and who had a specimen obtained for testing
prior to discharge or transfer, not including the admission AST (i.e.,
Discharge/Transfer AST Performed).
For patients’ with stays of > 3 days, enter the number of patients eligible
for discharge/transfer surveillance testing; were negative if tested on
admission. (i.e., Discharge/Transfer AST Eligible).
Outcome Measures (Optional) - MRSA & VRE ONLY

Prevalent Cases

Required for prevalent case - AST/clinical positive outcome measures.

AST/Clinical Positive

Enter the number of patients with MRSA and/or VRE isolated from a
specimen collected for AST or for clinical reasons on admission (≤ 3 days)
(i.e., the MRSA or VRE cannot be attributed to this patient care location).
Enter the number of patients with documentation on admission of MRSA
or VRE colonization or infection, from the admitting or referring facility,

Known Positive

January 2012

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Data Field

Incident Cases
AST/Clinical Positive

Custom Fields

Comments

January 2012

Instructions for Form Completion
in ≤ 12 months (i.e., patient is known to be colonized or infected with
MRSA and/or VRE within the last year). All MRSA or VRE colonized
patients already in the ICU during the first month of surveillance should be
considered “Known Positive”.
Required for incident case - AST/clinical positive outcome measures.
Enter the number of patients with a stay > 3 days:
• With no documentation on admission of MRSA and/or VRE
colonization or infection, from the admitting or referring facility,
in ≤ 12 months (i.e., patient is not known to be colonized or
infected with MRSA and/or VRE within the last year and is
negative if tested on admission), AND
• MRSA and/or VRE isolated from a specimen collected for AST or
clinical reasons > 3 days after admission and up to
discharge/transfer from the patient care location.

Optional. Up to 50 fields may be customized for local or group use
in any combination of the following formats: date (MMDDYYY),
numeric, or alphanumeric.
NOTE: Each custom field must be set up in the Facility/Custom Options
section of the application before the field can be selected for use.
Optional. Enter comments for local use and the values entered. These
fields may not be analyzed.

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