Infection Prevention Manual

EXPOSURE CONTROL PLAN HOME HEALTH INFECTION SURVEILLANCE REPORT Please complete this form on any home health patient if any of the following occurs: ! signs/symptoms of infection are present ! culture is done ! new antibiotic is ordered ! patient is admitted to hospital or dies due to a suspected infection ! patient has any acquired infection Patient name___________________ Date symptoms noted________________ Date of discharge from hospital/ECF___________ Diagnosis________________________ SUSPECTED SITE OF INFECTION: Blood IV Respiratory Wound Gastrointestinal Oral Urinary Other SIGNS/SYMPTOMS OF INFECTION: Physician diagnosis Fatigue Cloudy foul urine Increased cough or dyspnea Increased pain Increased sputum production Dysuria/suprapubic or flank pain White patchy area mouth Purulent drainage/wound drainage Diarrhea Erythema No findings(diagnosed in physician’s office) Fever, chills Other CULTURE : Date ordered _____________ Source ______________________ X-RAY : Date ordered _____________ Type/findings _______________ LAB : WBC ___________________ Results attached: ___Yes ___No ANTIBIOTIC : ___________________ Dosage _________________________ Date started _______ Route _____________ Frequency ______________ OTHER TREATMENT : _________________________________________________________________ _________________________________________________________________ Your Agency Name (PN System)