*required for saving **required for completion Facility ID:
|
Event #:
|
*Patient ID:
| Social Security #:
|
Secondary ID:
| |
Patient Name, Last: First: Middle:
|
*Gender: F M Other
| *Date of Birth:
|
Ethnicity (Specify):
| Race (Specify):
|
*Event Type: SSI
| *Date of Event:
|
*NHSN Procedure Code:
| ICD-9-CM Procedure Code:
|
*Date of Procedure: *Outpatient Procedure: Yes No
|
*MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO/CDI Module □ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO/CDI Module
|
*Date Admitted to Facility:
| Location:
|
Event Details
|
*Specific Event:
□ Superficial Incisional Primary (SIP) □ Superficial Incisional Secondary (SIS) □ Organ/Space (specify site): ______________
|
□ Deep Incisional Primary (DIP) □ Deep Incisional Secondary (DIS)
|
*Specify Criteria Used (check all that apply): Signs & Symptoms
□ Purulent drainage or material □ Pain or tenderness □ Localized swelling □ Redness □ Heat □ Fever □ Incision deliberately opened by surgeon □ Wound spontaneously dehisces □ Abscess □ Hypothermia □ Apnea □ Bradycardia □ Lethargy □ Cough □ Nausea □ Vomiting □ Dysuria □ Other evidence of infection found on direct
exam, during surgery, or by diagnostic tests‡
□ Other signs & symptoms‡
|
Laboratory
□ Positive culture □ Not cultured □ Positive blood culture □ Blood culture not done or no organisms detected in
blood
□ Positive Gram stain when culture is negative or
not done
□ Other positive laboratory tests‡ □ Radiographic evidence of infection
Clinical Diagnosis
□ Physician diagnosis of this event type □ Physician institutes appropriate antimicrobial
therapy‡
‡per organ/space specific site criteria
|
*Detected: □ A (During admission) □ P (Post-discharge surveillance) □ R (Readmission) *Secondary Bloodstream Infection: Yes No
|
**Died: Yes No
| SSI Contributed to Death: Yes No
|
Discharge Date:
| *Pathogens Identified: Yes No *If Yes, specify on pages 2-3.
|
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 32 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 57.120 (Front) Rev 3, v6.4
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