AGENCY NAME / LOGO
PATIENT INFECTION REPORT
Patient Name:
Acct #
DOB:
MR#
SOC Date:
Age:
ROC Date (if applic):
Diagnosis(es):
Has patient been in a health care facility within the last 30 days?
If yes, please indicate facility: ____Hospital*
Yes
____Nursing Home*
No.
Other*
(*Specify facility:
)
Infection Present on SOC date?
Yes
No
New infection/ symptoms identified on
(date).
Description:
________________________________________________________________________________________
TYPE/DESCRIPTION OF INFECTION
Vital Signs: T
 Surgical Site/Surgical Wound
 Peripheral IV  IVAD  PICC
 Tunneled Catheter  Temporary Central Line
R
BP
URINARY (Catheter related only)
 Indwelling (Foley)
 Supra-Pubic
 Intermittent by HV staff
 Intermittent by patient/family
Location:
 Dysuria
 Discharge
 Blood
 Odor
 Cloudy
 Other
 Redness:
 Drainage:
 Blisters:
 Skin tear/break:
 Rash:
 Cording:
 Other:
Culture done?
P
Yes
No Type:  Drainage Urine  Blood  Catheter tip
Results:
REPORTABLE/ RESISTANT DISEASES: (If yes, Please Specify using list on back of page)
Is a resistant organism known or suspected (Circle one)?
Yes
No: Organism:
Is a reportable disease known or suspected (Circle one)?
Yes
No: Disease:
Physician Notified?
No (Reason:
Yes (Date:
Name of Physician
);
)
Phone #
Patient/Family teaching (Specify what was taught):
Reported By (Please Print) :
Date:
Ext.
ROUTING: Please submit completed form to Director of Performance Improvement Dept. within 24 hrs. of identifying infection.
For any questions about completion of this form, phone P.I. Dept. Thank-you.
AGENCY NAME
Patient Infection Report
RESISTANT ORGANISMS:
MRSA (Methycillin Resistant Staphylococcus Aureus)
VRE (Vancomycin Resistant E. Coli)
ORSA (Oxycillin Resistant Staphylococcus Aureus)
OTHERS (Please specify organism on front)
 and Bold Type
NY STATE REPORTABLE DISEASES:
indicate need for phone reporting within 24 hours.
(Please submit written report to Performance Improvement ASAP and we will make phone call to Dept. of Health.)
Amebiasis
Histoplasmosis
 Poliomyelitis
Animal bites
Hospital associated infection (s)
Psittacosis
 Anthrax

Increased incidence/outbreak
Babesiosis

Staph/strep in newborns
Kawasaki syndrome
 Botulism
Legionellosis
Brucellosis
Leprosy
Camphylobacteriosis
Chancroid
 Cholera
 Rabies
Reye’s Syndrome
Rocky Mountain Spotted Fever
 Rubella
Leptospirosis
Salmonellaosis
Listeriosis
Shigellosis
Lyme Disease
Streptococcal Infections*
Cryptosporidiosis
Lymphogranuloma venereum
(invasive disease due to Group A
 Diphtheria
Malaria
E. Coli 0157:H7 infection
 Measles
 Syphilis
Encephalitis
Meningitis
Tetanus
beta hemolytic strep)
 Foodborne illness (specify agent)
Aseptic
Toxic Shock Syndrome
Giardiasis
 Haemophilus
Trichinosis
Gonococcal infection
 Meningiococcal
Granuloma inguinale
 Haemophilus influenzae
(Invasive Disease)
Other (specify type)
 Meningiococcemia
 Mumps
Hantavirus Disease
Hemolytic Uremic Syndrome
 Pertussis (whooping Cough)
 Hepatitis A
 Plague
Hepatitis B
Pneumococcal infections*
Hepatitis C
(invasive disease due to antibiotic
Hepatitis non-A, non-B
resistant streptococcus pneumoniae)
 Tuberculosis
Tularemia
 Typhoid
 Typhus
 Yellow fever
Yersiniosis
*Report only cases with positive cultures from blood, CSF, joint, peritoneal, or pleural fluids
OTHER REPORTABLE infection related diseases for Agency follow-up:
C. Difficile
Adult conjunctivitis
E. Coli
Any Strep. infection
Herpes
Any death due to known or suspected communicable disease
Pediculosis
Any hospitalization due to known or suspected communicable disease