Form 57.402 Outpatient Procedure - Event

Form Approved

OMB 0920-xxxx

Exp. Date xx/xx/20xx

www.cdc.gov/nhsn

Outpatient Procedure Component Event

Page 1 of 1

*required for saving

Facility ID:

Event #:

*Patient ID:

Social Security #:

Secondary ID #:

Medicare #:

Patient Name, Last:

First:

Middle:

*Gender: F M Other

*Date of Birth:

Ethnicity (Specify):

Race (Specify):

*Date admitted to facility where procedure occurred (MM/DD/YYYY):

Four Same Day Outcome Measures

*Specify event: (check all that apply)

□ Patient burn

□ Patient fall

□ Hospital transfer/admission

□ Wrong site

□ Wrong side

□ Wrong patient

□ Wrong procedure

□ Wrong implant

Prophylactic IV Antibiotic Timing

□ Had an order for a prophylactic IV antibiotic that was NOT administered on time

Surgical Site Infection (SSI)

*Date of SSI: ____/____/______

*Primary CPT Code:________

NHSN Procedure Code:­­­­­________

*Specific event (type of SSI):

□ Superficial incisional

□ Deep incisional

□ Organ/space

*How infection was first reported: (Check all that apply):

□ Surgeon

□ Attending physician other than surgeon

□ Admitting inpatient facility

□ Routine follow-up at outpatient facility

□ Patient or family member

*Specify SSI criteria used (check all that apply):

Signs & Symptoms

Laboratory

□ Purulent drainage

□ Redness

□ Positive culture

□ Incision deliberately opened/drained

□ Heat

□ Not cultured

□ Pain or tenderness

□ Abscess

□ Imaging test evidence of infection

□ Localized swelling

□ Fever (>38C)

□ Histopathologic evidence of infection

□ Wound spontaneously dehisces

Other

□ Diagnosis of superficial SSI by surgeon or attending physician

□ Other evidence of infection on direct exam or during invasive procedure

*Pathogens identified: □ Yes □ No

If Yes, indicate up to 3 pathogens:

_________________

_________________

_________________

Custom Fields

Label

Label

__________________

____/____/____

__________________

__________________

Comments

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 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.402 v8.1