Form 57.403 Outpatient Procedure - Monthly Denominators and Summary

Form Approved

OMB No. 0920-xxxx

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Outpatient Procedure Component

Monthly Denominators and Summary

Page 1 of 1
*required for saving
Facility ID: ________________						*Month/Year: ________ /_________
Same Day Outcome Measures
*Total number of admissions for the month: __________
Prophylactic IV Antibiotic Timing
*Number of admissions:
With an order for a prophylactic IV antibiotic that was administered on time:______
With an order for a prophylactic IV antibiotic that was NOT administered on time: _______
With no order for a prophylactic IV antibiotic: ______
(Sum of 1, 2, and 3 should equal total number of admissions for the month)
Surgical Site Infections Surveillance
*Procedure Category (NHSN Code)+:			*Total Number of Admissions with a Primary CPT Code in the Category†:
_____________			_____________
_____________			_____________
_____________			_____________
_____________			_____________
+NHSN Codes for Procedure Categories:
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)
† Instructions and code mapping chart can be found on the tables of instructions for this form or in the NHSN Outpatient Procedure Component Protocol
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 40 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 57.403 v8.1