HOME HEALTH - National Association for Home Care & Hospice
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
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