Form 57.401 Outpatient Procedure - Monthly Reporting Plan

Form Approved

OMB No. 0920-xxxx

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Outpatient Procedure Component

Monthly Reporting Plan

Page 1 of 1
*required for saving
Facility ID: ________________		*Month/Year: ________ /_________
No NHSN Outpatient Procedure reporting this month: □
Same Day Quality Measures
□ Four Same Day Outcome Measures+
□ Prophylactic IV Antibiotic Timing
+The Four Same Day Outcome Measures include the following ASC Quality Measures: 1) Patient Burn; 2) Patient Fall; 3) Wrong Site, Side, Patient, Procedure, or Implant; 4) Hospital Transfer/Admission
Surgical Site Infection (SSI) Surveillance
Targeted SSI surveillance for specific NHSN Operative Procedure Categories
Specify which procedure categories are being monitored (check all that apply):
□ BRST (Breast)	□ CHOL (Gallbladder)
□ COLO (Colon)	□ FX (Open reduction of fracture)
□ HER (Herniorrhaphy)	□ HPRO (Hip arthroplasty)
□ HYST (Abdominal hysterectomy)	□ KPRO (Knee arthroplasty)
□ LAM (Laminectomy)	□ VHYS (Vaginal hysterectomy)
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Project Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.401 v8.1