Form 57.404 Outpatient Procedure Component - SSI Denominators

OMB 0920-0666

Exp. Date xx/xx/20xx

www.cdc.gov/nhsn

Outpatient Procedure Component

Surgical Site Infection (SSI) Event

This form is used for reporting data on each patient having a SSI event related to one of the NHSN operative procedures selected for monitoring.

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*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 of Encounter (MM/DD/YYYY):

Surgical Site Infection (SSI)

*Event Type: __________

*Date of SSI: ___/____/____

Primary CPT Code:________

*NHSN Procedure Code: _______

*SSI Level:

□ Superficial Incisional Primary (SIP) □ Superficial Incisional Secondary (SIS)

□ Deep Incisional Primary (DIP) □ Deep Incisional Secondary (DIS)

□ Organ/Space

*Specify SSI Criteria Used (check all that apply):

Signs & Symptoms

Laboratory

□ Abscess □ Erythema or redness □ Fever (>38oC) □ Heat □ Incision deliberately opened/drained

□ Localized swelling □ Pain or tenderness □ Purulent drainage □ Wound spontaneously dehisces

□ Organism(s) identified □ Culture or non-culture based testing not performed □ Imagining test evidence of infection

□ Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam

Clinical Diagnosis

□ Diagnosis of superficial SSI by surgeon or attending physician

*Pathogens Identified: □ Yes □ No

If Yes, indicate up to 3 pathogens:

_______________

_______________

_______________

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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 35 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 57.405 (Front), V8.8

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SSI Event Detected:
*How did the outpatient facility (where the procedure was originally performed) detect/identify the SSI event? (select the method that most closely resembles the method of detection/identification)
The SSI was detected through the facility’s formal active surveillance process:				The SSI was detected through a passive process that was not initiated by the facility:
Review of patient’s medical record Post-discharge surgeon survey Post-discharge patient letter Post-discharge patient phone call Patient returns to outpatient facility for follow-up Cooperative infection prevention process between facilities				Patient/caregiver contacts facility to report Surgeon contacts facility to report Report from another facility (inpatient, health department, emergency department, etc.)
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