Reference no: EM132933146

Use the health record to complete the Report of Infections or Suspected Infection form Access health record REPORT OF INFECTIONS OR SUSPECTED INFECTIONS

NOTE: This form is to be used for all known and suspected skin and wound infections. (Patient, staff doctors, house officers, student nurses, private duty nurses and hospital employees.) Submit immediately to the Nursing Office. A report must be made on all patients admitted into isolation as well as those developing later signs and symptoms.

1. Name _____________________________ Room No. _______ Hospital No. __________
Doctor ______________________________ Date admission ______________________

2. Was infection present on admission? Yes.____ No.____

3. If not on admission-Date infection noted _______ Date operation (if surgery) _______

4. Location/extent/signs infection ________/__________/________________________

5. Date culture was taken _______________. If not cultured, why not? ________________
Organism isolated ________________________________________________________

6. Date patient isolated ___________. If not isolated, why not? ______________________

7. Has any other member of the patient's family been in a hospital, been treated at home or as an outpatient for an infection? Yes. _______ No. ________

8. Signature of nurse starting the report: _________________________________________
IF WOUND INFECTION, COMPLETE SECTION 8. (OR Supervisor) ________________________________________________________________________

9. Name operation procedure ______________________ Surgeon ____________________
Assistant ____________________________ Suture nurse _________________________
Circulating nurse ______________________________________ O.R. No. ________
Length operation _____ Skin Prep ___________________________________________

FOR USE BY MEDICAL STAFF INFECTION MONITOR

1. Was infection expected? Yes. _____ No. ______

2. Will it prolong or complicate convalescence? Yes. ______ No.______

3. Were correct isolation and other indicated procedures instituted? Yes. ____ No. ____
If not, why? __________________________________________________________

4. Treatment adequate Yes. ____ No. _____ If no, comment ______________________

5. Any breech of technique or other casual factors noted _________________________________

6. Other factors or information _____________________________________________

Attachment:- Case.rar