Denominatoir for Procedure

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Denominator for Procedure
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*required for saving
Facility ID
Procedure #:
*Patient ID:
Social Security #:
Secondary ID:
Medicare #:
Patient Name, Last:
First:
Middle:
*Gender:   F    M    Other
*Date of Birth:
Ethnicity (Specify):
Race (Specify):
Event Type: PROC
*NHSN Procedure Code:
*Date of Procedure:
ICD-10-PCS or CPT Procedure Code:
Procedure Details
*Outpatient:  Yes    No
*Duration: ______Hours  ______Minutes
*Wound Class:  C    CC    CO    D    
*General Anesthesia:  Yes    No
ASA Score:  1   2   3   4   5
*Emergency:  Yes     No
*Trauma:  Yes    No
     *Scope:  Yes    No             *Diabetes Mellitus:  Yes    No
*Height: ______feet  _______inches  
*Closure Technique:  Primary       Other than primary
(choose one) ________meters
*Weight: ________lbs/kg (circle one)
 Surgeon Code: _____________
CSEC:   *Duration of Labor: ______hours   


Circle one: FUSN

*Spinal Level (check one)

□ Atlas-axis

□ Atlas-axis/Cervical
*Approach/Technique (check one)
□ Cervical
□ Anterior
□ Cervical/Dorsal/Dorsolumbar
□ Posterior
□ Dorsal/Dorsolumbar
□ Anterior and Posterior
□ Lumbar/Lumbosacral
□ Transoral


Circle one: HPRO    KPRO
   *Check one:   □ Total   
□ Hemi   
□ Resurfacing (HPRO only)
 If Total:  
□ Total Primary     
□ Total Revision   

 If Hemi:  
□ Partial Primary  
□ Partial Revision

If Resurfacing (HPRO only) :    
□ Total Primary     
□ Partial Primary

     If total or partial revision, was the revision associated with prior infection at index joint?                                         
□ Yes
□ No
Assurance of Confidentiality:  The 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 5 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 57.121 Rev. 7, NHSN v8.5
Denominator for Procedure
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