ViaHealth Home Care Infection Report
AGENCY NAME / LOGO PATIENT INFECTION REPORT
Patient Name: DOB: Age:
Acct # MR# SOC Date: ROC Date (if applic):
Diagnosis(es):
Has patient been in a health care facility within the last 30 days? Yes No.
If yes, please indicate facility: ____Hospital* ____Nursing Home* Other*
(*Specify facility: )
Infection Present on SOC date? Yes No
New infection/ symptoms identified on (date). Description:
________________________________________________________________________________________
| |
|TYPE/DESCRIPTION OF INFECTION Vital Signs: T P R BP |
|( Surgical Site/Surgical Wound |URINARY (Catheter related only) |
|( Peripheral IV ( IVAD ( PICC |( Indwelling (Foley) ( Supra-Pubic |
|( Tunneled Catheter ( Temporary Central Line |( Intermittent by HV staff |
| |( Intermittent by patient/family |
|Location: | |
| |( Dysuria |
|( Redness: |( Discharge |
|( Drainage: |( Blood |
|( Blisters: |( Odor |
|( Skin tear/break: |( Cloudy |
|( Rash: |( Other |
|( Cording: | |
|( Other: | |
| |
|Culture done? Yes No Type: ( Drainage (Urine ( Blood ( Catheter tip |
| |
|Results: |
| |
|REPORTABLE/ RESISTANT DISEASES: (If yes, Please Specify using list on back of page) |
| |
|Is a resistant organism known or suspected ((Circle one)? Yes No: Organism: |
| |
|Is a reportable disease known or suspected ((Circle one)? Yes No: Disease: |
Physician Notified? Yes (Date: ) ; No (Reason: )
Name of Physician Phone #
Patient/Family teaching (Specify what was taught):
Reported By (Please Print) : Date: Ext.
AGENCY NAME Patient Infection Report
RESISTANT ORGANISMS:
MRSA (Methycillin Resistant Staphylococcus Aureus) VRE (Vancomycin Resistant E. Coli)
ORSA (Oxycillin Resistant Staphylococcus Aureus) OTHERS (Please specify organism on front)
NY STATE REPORTABLE DISEASES: ( and Bold Type indicate need for phone reporting within 24 hours. (Please submit written report to Performance Improvement ASAP and we will make phone call to Dept. of Health.)
|Amebiasis |Histoplasmosis |( Poliomyelitis |
|Animal bites |Hospital associated infection (s) |Psittacosis |
|( Anthrax |Increased incidence/outbreak |( Rabies |
|Babesiosis |Staph/strep in newborns |Reye’s Syndrome |
|( Botulism |Kawasaki syndrome |Rocky Mountain Spotted Fever |
|Brucellosis |Legionellosis |( Rubella |
|Camphylobacteriosis |Leprosy |Salmonellaosis |
|Chancroid |Leptospirosis |Shigellosis |
|( Cholera |Listeriosis |Streptococcal Infections* |
|Cryptosporidiosis |Lyme Disease |(invasive disease due to Group A |
|( Diphtheria |Lymphogranuloma venereum |beta hemolytic strep) |
|E. Coli 0157:H7 infection |Malaria |( Syphilis |
|Encephalitis |( Measles |Tetanus |
|( Foodborne illness (specify agent) |Meningitis |Toxic Shock Syndrome |
|Giardiasis |Aseptic |Trichinosis |
|Gonococcal infection |( Haemophilus |( Tuberculosis |
|Granuloma inguinale |( Meningiococcal |Tularemia |
|( Haemophilus influenzae |Other (specify type) |( Typhoid |
|(Invasive Disease) |( Meningiococcemia |( Typhus |
|Hantavirus Disease |( Mumps |( Yellow fever |
|Hemolytic Uremic Syndrome |( Pertussis (whooping Cough) |Yersiniosis |
|( Hepatitis A |( Plague | |
|Hepatitis B |Pneumococcal infections* | |
|Hepatitis C |(invasive disease due to antibiotic | |
|Hepatitis non-A, non-B |resistant streptococcus pneumoniae) | |
*Report only cases with positive cultures from blood, CSF, joint, peritoneal, or pleural fluids
OTHER REPORTABLE infection related diseases for Agency follow-up:
C. Difficile Adult conjunctivitis
E. Coli Any Strep. infection
Herpes Any death due to known or suspected communicable disease
Pediculosis Any hospitalization due to known or suspected communicable disease
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