Form CDC 57.121 CDC 57.121 Denominator for Procedure

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Denominator for Procedure

Page 1 of 1

*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-9-CM 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 RFUSN

*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

□ Partial Revision

If Hemi:

□ Partial Primary

□ Total Revision

□ Partial Revision

If Resurfacing (HPRO only) :

□ Total Primary

□ Total Revision

□ Partial Primary

□ Partial Revision

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. 6, NHSN v8.3

Denominator for Procedure

Custom Fields
Label		Label
______________________	___ /____/______	______________________	___ /____/______
______________________	___ /____/______	______________________	___ /____/______
______________________	___ /____/______	______________________	___ /____/______
______________________	___ /____/______	______________________	___ /____/______
______________________	___ /____/______	______________________	___ /____/______
______________________	___ /____/______	______________________	___ /____/______
______________________	___ /____/______	______________________	___ /____/______
Comments