Patient Nosohusial Infection Report Form

HOME HEALTH

Patient Nosohusial Infection Report Form

Pt. Name ______________________________________________Report Date____________________

Date of Admission to Home Health ______________________Physician________________________

Admitting Diagnosis___________________________________ Referring Facility_________________

Site of Infection Risk Factors (circle any that apply)

Urinary Foley catheter intermittent cath

suprapubic catheter peri care by Aide

Respiratory tracheostomy ventilator humidifier

inhaler treatments croup tent

Gastrointestinal PEG tube NG tube OG tube

meal prep. by Aide

Bloodstream/IV peripheral line central line midline

injections venipuncture

Surgical Wound* wound care drain tube adhesives wound care product whirlpool

Skin/Soft Tissue * assistive device wound care brace

immobilizer indwelling tube whirlpool

wound care product adhesives

Date of infection _________________________ Date of Surgery_____________________________

Infection developed at least 72 hours after admit to HH ? YES NO

Infection developed at least 30 days after surgery? YES NO

Dr. notified? YES , date_____________________ NO, comment____________________________

Therapy/medication ordered_________________________________________________________

Culture ordered? YES NO

Culture source____________________________________ Date done________________________

Signature of Nurse_____________________________________________________________________

*Surgical wounds are new infections after an initial negative assessment within 30 days of surgery

*Skin/Soft Tissue are new infections after 30 days of surgery

Infection Control reported statistically as : Nosocomial Nosohusial Community