2015 CAMC UR & SINU – Upper Respiratory Tract Infection & Sinusitis Worksheet
Name
DOB
MR #
Age
M
F
Account #
Admitting Diagnosis
Birthweight (gms)
(Neonates only)
Test Period
Unit
Event Date
Medicare ID #
Pt expire
Yes No
Admit date
D/C date
ICU Admit date
ICU D/C date
Attending / ID Consultant
Culture date
Pathogen(s)
Culture Site
Culture date
Pathogen(s)
Culture Site
SINU-Sinusitis
Sinusitis must meet at least one of the following criteria:
Date
1.
Patient has organisms cultured from fluid or tissue from the sinus cavity obtained during an invasive procedure.
2.
Patient has at least one of the following signs or symptoms: fever (>38.0°C±), pain or tenderness over the involved sinus*,
headache*, purulent exudate*, or nasal obstruction*
AND
Imaging test evidence of sinusitis (e.g., x-ray, CT scan)
* With no other recognized cause
± As documented in the medical record
UR-Upper respiratory tract infection, pharyngitis, laryngitis, epiglottitis
Upper respiratory tract infections must meet at least one of the following criteria:
Date
1.
Patient has at least two of the following signs or symptoms: fever (>38.0°C±), erythema of pharynx*, sore throat*, cough*,
hoarseness*, or purulent exudate in throat*
AND at least one of the following:
a. Organisms cultured from upper respiratory site [i.e. larynx, pharynx, and epiglottis] (Note: excludes sputum
because sputum is not an upper respiratory specimen)
b. Positive non-culture diagnostic laboratory test from upper respiratory site [i.e. larynx, pharynx, and epiglottis]
(Note: excludes sputum because sputum is not an upper respiratory specimen)
c.
Diagnostic single antibody titer (IgM) or 4-fold increase in paired sera (IgG) for organism
d.
Physician diagnosis of an upper respiratory infection
2.
Patient has an abscess on gross anatomical or histopathologic exam or imaging test.
3.
Patient ≤1 year of age has at least two of the following signs or symptoms: fever (>38.0°C±), hypothermia (<37.0°C± ), apnea*,
bradycardia*, nasal discharge*, or purulent exudate in throat*
AND at least one of the following:
a. Organisms cultured from upper respiratory site [i.e. larynx, pharynx, and epiglottis] (Note: excludes sputum
because sputum is not an upper respiratory specimen)
b. Positive non-culture diagnostic laboratory test from upper respiratory site [i.e. larynx, pharynx, and epiglottis]
(Note: excludes sputum because sputum is not an upper respiratory specimen)
c.
Diagnostic single antibody titer (IgM) or 4-fold increase in paired sera (IgG) for organism
d.
Physician diagnosis of an upper respiratory infection
* With no other recognized cause
± As documented in the medical record
Notes/Comments:
2015 CAMC UR & SINU – Upper Respiratory Tract Infection & Sinusitis Worksheet
Unit
RIT
Infection
Window
Period
Date of Event
Hospital
Day
Date
Table of Events
Infection Window Period (first + diagnostic test, 3 days before & 3 days after) Repeat Infection Timeframe-RIT (14 day timeframe where date of event = day 1)
Date of Event (date the first element occurs for the first time within the infection window period) Secondary BSI Attribution Period (Infection Window Period + RIT)