Tiêu đề PHICNA HAI Surveillance Form.pdf ✅

Name __________________________________ Age _________ Sex _____________ Devices Inserted Date of Insertion Location of Insertion Date of Removal Area/Room/Bed No. _______________________ Date of Discharge ____________________________ Date of Admission ________________________ Outcome (Alive/Discharged/Dead) ________________ Admitting/Running Diagnosis ______________________________________________________________________ Birth Weight in Grams ___________________ (For NICU only) Procedure/s Done _______________________________________________________________________________ Date of Procedure/s _______________________ Date of Event □ PNEU □ PNU1 □ PNU2 □ PNU3 □ VAE □ VAC □ IVAC □ PVAP APRV: □ Yes □ No □ CLABSI □ LCBI1 □ LCBI2 □ LCBI3 □ MBI- LCBI1 □ MBI- LCBI2 □ MBI- LCBI3 Vetricular Assist Device Present: □ Yes □ No □ CAUTI □ SUTI □ ABUTI Urinary Catheter Status: □ In place – Urinary catheter in place > 2 days on the date of event or present for any portion of the □ Removed – Urinary catheter in place > 2 days and removed the day before the date of event □ Neither – Not catheter associated –Neither in place nor removed □ SSI □ SIP □ SIS □ DIP □ DIS □ Organ/ Space (specify site): Physician Diagnosis: □ Yes □ No FiO2 PEEP RBC Pus Cells Contraptions *For Signs & Symptoms, please take note of the following: PNEU - Fever, Hypothermia, Leukopenia or leukocytosis, Cough, Altered Mental Status (≥70 y.o.), New onset/change in sputum, New onset/worsening cough, Tachypnea, Dyspnea, Apnea, Worsening Gas Exchange, Hemoptysis, Nasal flaring with retraction of chest wall or grunting, Tachycardia, Bradycardia, Abnormal Breath Sounds CAUTI - Any Patient: Fever, Frequecy, Pain or Tenderness, Acute pain, swelling, or tenderness of testes, epididymis, or prostate, Suprapubic tenderness, Costovertebral angle pain or tenderness, Purulent drainage from affected site, Urgency, Dysuria, Abscess, Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam ≤ 1 year old: Fever, Hypothermia, Apnea, Bradycardia, Lethargy, Vomiting, Suprapubic tenderness CLABSI - Any Patient: Fever, Chills, Hypotension ≤ 1 year old: Fever, Hypothermia, Apnea, Bradycardia SSI - Drainage or material, Pain or tenderness, Swelling or inflammation, Erythema or redness, Heat, Fever, Incision deliberately opened/drained, Wound spontaneously dehisces, Abscess, Sinus tract, Hypothermia, Apnea, Bradycardia, Lethargy, Cough, Nausea, Vomiting, Dysuria, Other evidence of infection found on invasive procedure, gross anatomic exam, or histopathologic exam Urinalysis Result/s Urine GS/CS Result/s Kindly take note of the highest or lowest value of the day. Wound GS/CS HEALTHCARE ASSOCIATED INFECTIONS (HAI) SURVEILLANCE FORM (FORM 3) Date Blood GS/CS Result/s Antibiotics *Other Signs & Symptoms WBC Count Temp. Mechanical Ventilator Settings Sputum/ETA GS/CS Result/s Sputum Character CXR Result/s Lung Sounds Philippine Hospital Infection Control Nurses Association (PHICNA), Inc. PRC CPD Provider Accreditation No. 2017-142 Adapted from CDC NHSN Data Collection Forms 2018