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Clostridium difficle Infection Line List

Pt.Roomat Symptom Onset # Unit

FacilityName___________________________________
#Daysin Room before Symptom Onset Date

Case#

Case initials

MR#

Symptom OnsetDate (Diarrhea)

Dateof Current Admit

DateofLast D/Cfrom Admitting Facility

LabTest Dateof PositiveLab Toxin Result

CDIClassification
Severe CDI (Y/N)

A/B Other(Specify) EIA

CA

COHA HOHA

Indeter Un minate known

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