Scribd Logo
Upload

Welcome to Scribd!

  • 357 views

    Infection Control Incident Report

    Uploaded by

    yolanda
    This document is an infection control incident report form used to report any signs or symptoms of infection in a resident. It collects information such as the resident's name and ID, signs and symptoms of infection they are exhibiting by checking boxes, any invasive devices they have, details of any cultures taken or antibiotics ordered, and their current status like if they were admitted to the hospital or expired due to the suspected infection. The form aims to document infection control incidents in residents for monitoring and response.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Infection Control Incident Report

    Uploaded by

    yolanda
    357 views1 page
    This document is an infection control incident report form used to report any signs or symptoms of infection in a resident. It collects information such as the resident's name and ID, signs and symptoms of infection they are exhibiting by checking boxes, any invasive devices they have, details of any cultures taken or antibiotics ordered, and their current status like if they were admitted to the hospital or expired due to the suspected infection. The form aims to document infection control incidents in residents for monitoring and response.

    Original Title

    Infection Control Incident Report.doc

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is an infection control incident report form used to report any signs or symptoms of infection in a resident. It collects information such as the resident's name and ID, signs and symptoms of infection they are exhibiting by checking boxes, any invasive devices they have, details of any cultures taken or antibiotics ordered, and their current status like if they were admitted to the hospital or expired due to the suspected infection. The form aims to document infection control incidents in residents for monitoring and response.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    357 views1 page

    Infection Control Incident Report

    Uploaded by

    yolanda
    This document is an infection control incident report form used to report any signs or symptoms of infection in a resident. It collects information such as the resident's name and ID, signs and symptoms of infection they are exhibiting by checking boxes, any invasive devices they have, details of any cultures taken or antibiotics ordered, and their current status like if they were admitted to the hospital or expired due to the suspected infection. The form aims to document infection control incidents in residents for monitoring and response.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    INFECTION CONTROL INCIDENT REPORT

    Facility Name
    Complete this form on any resident if: Todays date _____________
    there are signs and symptoms of infection OR
    a culture is done OR
    an antibiotic/antifungal is ordered OR
    the resident is transferred to the hospital or expires due to a suspected infection

    Residents name _______________________ Medical record number ________________

    Signs and Symptoms (Check all that apply)


    1. [ ] Breath sounds, abnormal : rales, 43. [ ] Other signs and symptoms of infection
    rhonchi, wheezes, bronchial breathing Specify __________________
    2. [ ] Change in functional status (ADLs) 44. [ ] Physician sees resident and diagnosis
    3. [ ] Change in mental status (worsening) infection Site ______________
    4. [ ] Conjunctival redness
    5. [ ] Cough, dry Invasive devices
    6. [ ] Cough, increased A. [ ] Urinary catheter
    7. [ ] Cough, new B. [ ] Suprapubic catheter
    8. [ ] Cough, productive C. [ ] Self intermittent catheterization
    9. [ ] Diarrhea, loose or watery stool D. [ ] Assisted intermittent
    10. [ ] Difficulty swallowing catheterization
    11. [ ] Drainage, foul-smelling Site ______ E. [ ] Permanent intravenous catheter
    12. [ ] Drainage, serous Site ___________ F. [ ] Peripheral intravenous catheter
    13. [ ] Fever _____ oF or _____ oC G. [ ] PICC line
    14. [ ]
    Headache or eye pain H. [ ] Tracheostomy
    15. [ ]
    Heat Site _______________ I. [ ] J- or G-tube
    16. [ ]
    Hoarseness J. [ ] Nasogastic tube
    17. [ ]
    Hypotension (< 90 mm Hg systolic) K. [ ] Surgical drain
    18. [ ]
    Incontinence, new or worse L. [ ] Subcutaneous infusion
    19. [ ]
    Loss of appetite M. [ ] Other device
    20. [ ]
    Malaise Specify ________________
    21. [ ]
    Muscle aching
    22. [ ]
    Pink eye Culture
    23. [ ]
    Pleuritic chest pain Date obtained ______________
    24. [ ]
    Pus present Site _______________ Source ______________
    25. [ ]
    Rash, itching
    26. [ ]
    Rash, maculopapular X-ray
    27. [ ]
    Rash, vesicular Date obtained ______________
    28. [ ]
    Redness Site _______________ Type ______________
    29. [ ]
    Respiratory rate increased (> 25/min.)
    30. [ ]
    Runny nose Antibiotic/antifungal ordered
    31. [ ]
    Shortness of breath, new or worse Date ordered ______________
    32. [ ]
    Sneezing Name of medication ______________
    33. [ ]
    Sore throat
    34. [ ]
    Sputum, increased Patient Status
    35. [ ]
    Stuffy nose (nasal congestion) [ ] Remained in facility
    36. [ ]
    Swelling Site _______________
    37. [ ]
    Swollen or tender neck glands [ ] Admitted to hospital
    38. [ ]
    Tenderness Site _______________ Name of hospital ________________
    39. [ ]
    Urinating problems (new): pain, Date of admission _______________
    frequency or urgency Reason for admission _____________
    40. [ ] Urine, abnormal urinalysis
    41. [ ] Urine, change in character, visual [ ] Expired
    or smell
    42. [ ] Vomiting, 3 or more episodes in 24
    hours

    You might also like