INDIVIDUAL RESIDENT INFECTION SURVEILLANCE REPORT
|INDIVIDUAL RESIDENT INFECTION SURVEILLANCE REPORT |
|DATE |PHYSICIAN |
|ROOM NO. MR NO. |RESIDENT |
|ADMIT DATE |DISCHARGE DATE |EXPIRED |
|DATE SYMPTOMS DEVELOPED |TPR |
|LIST SYMPTOMS | | |
| | | |
| | | |
| | | | |
|TYPE OF INFECTION |( URI |( UTI |( SKIN |
| | | | |
| |( WOUND |( EYE |( OTHER ____________ |
| |
|CULTURE ( Yes ( No |
|ORGANISM (1) _____________________________ (2) ___________________________ |
|A. If UTI: Bacteria Count ______________________________ |
|Foley ( Yes ( No |
|B. If UTI: Results ______________________________ |
|Chest X-Ray ( Yes ( No |
|MEDICATION |
|PRECAUTIONS/ISOLATION (type) |
|DATE INFECTION CLEARED |
| |
|INFECTION PRESENT AT ADMISSION Yes No |
| |
|INFECTION DEVELOPED AFTER ADMISSION Yes No |
| |
|REPORTED TO INFECTION CONTROL COMMITTEE Yes No |
|NURSE SIGNATURE |
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