OMB
0920-0666
Exp. Date 01/31/2021
www.cdc.gov/nhsn
Outpatient Procedure Component Same Day Outcome
Measures Event
This form is used for reporting data on each patient who experienced one or more of the Same Day Outcome Measures events.
Instructions for this form are available at: https://www.cdc.gov/nhsn/forms/instr/57.402-toi.pdf.
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*required for saving |
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Facility ID: |
Event #: |
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*Patient ID: |
Social Security #: |
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Secondary ID #: |
Medicare #: |
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Patient Name, Last: |
First: |
Middle: |
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*Gender: F M Other |
*Date of Birth: |
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Sex at Birth: F M Unknown |
Gender Identity (Specify): |
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Ethnicity (Specify): |
Race (Specify): |
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*Date of Encounter (Admission) at the Outpatient Procedure Center (MM/DD/YYYY): |
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Same Day Outcome Measures |
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*Specify event: (check all that apply) |
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□ Patient burn |
□ Patient fall |
□ Hospital transfer/admission |
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Wrong Event (check any that apply) |
□ Wrong side |
□ Wrong patient |
□ Wrong procedure |
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□ Wrong site |
□ Wrong implant |
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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)).
CDC 57.402 |
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January 2023
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Amy Schneider |
File Modified | 0000-00-00 |
File Created | 2023-11-19 |