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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download