Nosocomial Infection Surveillance Form

Sticker Name

Diagnosis…………………………………………………………………..

History illness DM HT Heart ESRD Cirrhosis

Thrombocytopenia
Hematologic cancer other Cancer HIV
Thyroid CVA

SSI (Surgical site Infection) : Heart surgery, CABG surveillance 90

Days, Heart Kidney transplant surveillance 30 Days

Operation…………………………………….Date…………………………Started……………..Finished……
…….Total…….hr……….mins

ASA class 1 2 3 4 Wound class 1 2

3 4

Level Superficial incisional SSI Surgeon…………………………………

Deep incisional SSI

Organ/ Space incisional SSI

Pathogen…………………………………….Date…………………………..ATB………………………………………Ti
me…………………………….

Symptoms Fever > 38C Yellow, Brown pus Pain, redness,

swelling Split wound

Primary Bacteremia

Symptoms Fever > 38C Blood culture Positive

Pathogen…………………………..Date………………….

Secondary Bacteremia Date…………………………( Source of

infection……………………………..)

Peripheral line
 Central line ( AVF, DLC, Port, UVC)
On……………………Off………………….Total……………….Days

Skin and soft tissue Infection Procedure Yes

NO

Date…………………………………….. Specific………………………………………..

Fever > 38C Pathogen…………………………………

IV Phlebitis

Cellulites

Burn

Bed sore

Other ( Stitch off, Drain, …….)

Urinary tract Infection (CAUTI, UTI) Foley s

catheter Yes NO
Date……………………….
On……………………Off………………….Total……………….Days

Pathogen…………………………………………..

Respiratory Tract Infection (Ventilator associated pneumonia, Hospital

acquired pneumonia)

CXR Date……………………………………………. Result………………………………

Ventilator No On……………………………………..Off…………………………………………
Total ……………………..Days

Pathogen…………………………………….

Other
 Bronchitis Lung abscess Emphysema
Sinusitis Influenza

Antibiotic

ATB On Date Off Date Cost

Outcome

NI Yes No

Dead Yes No