INFECTION CONTROL REPORT FORM - Becker's ASC Review
INFECTION CONTROL REPORT FORM
Form to be completed by the Attending Physician or a Nurse in all cases of infection. Original to remain on patient’s chart; duplicate to be reviewed by the Total Quality Management Committee and reported as part of the Infection Control Report to the Board of Managers.
This form shall be completed on: All patients with post-operative infection
Patient MR#________________ DOS___________Sex____________Age___________
Procedure: _____________________________________Physician__________________
1. Date/Time_____________________________________________________
2. Findings______________________________________________________
____________________________________________________________
_____________________________________________________________
____________________________________________________________
3. Type of infection
a. Fever ___________________________________________________
b. Notifiable disease__________________________________________
c. Septicemia (bacteremia)_____________________________________
d. Surgical wound____________________________________________
e. Patient diabetic yes no
f. Patient Hygiene good fair poor no information available
g. Patient co-morbidities ______________________________________
________________________________________________________
i. Infection related to an implant? Yes_____ No_______
If yes, what was implanted and when.__________________________
__________________________________________________________
4. Was infection cultured? Yes________ No_________ Date__________
Result of culture________________________________________________ _____________________________________________________________
5. Antibiotics used________________________________________________
_____________________________________________________________
6. Was the surgical site shaved prior to prep: Yes No
How was surgical site prepped?
a. Betadine gel
b. Betadine paint and scrub
c. Hibiclens
d. Other____________________________
7. Sterilization records reviewed: Yes No
Pertinent Findings______________________________________________
8. Practitioner’s comment and recommendations________________________
_____________________________________________________________
RN___________________Admin.______________________Physician_________________
Source: Suzette Rieger, Cleburne Surgical Center. Adapted and reprinted with permission.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- surgical procedure checklist
- association of perioperative registered nurses aorn
- clinical audit proposal form rstn
- antibiotic audit tool agency for healthcare research and
- audit of approved animal care and use protocol
- audit element minnesota hospital association
- facilitator guide auditing your briefings and debriefings
- infection control report form becker s asc review
- observation form who
- procedural safety checklist audit
Related searches
- nevada cosmetology infection control course
- infection control in outpatient setting
- outpatient infection control guidelines
- basic infection control inservice hando
- basic infection control inservice handouts
- infection control plan ambulatory care
- infection control for ambulatory settings
- cdc ambulatory infection control guidelines
- cdc infection control guidelines 2019
- infection control standard precautions in health care
- infection control in cosmetology
- types of infection control precautions