2015 CAMC BONE – Osteomyelitis Worksheet
Name
DOB
MR #
Age
M
F
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
Account #
Admitting Diagnosis
Attending / ID Consultant
Culture date
Pathogen(s)
Culture Site
Culture date
Pathogen(s)
Culture Site
BONE – Osteomyelitis
Osteomyelitis must meet at least one of the following criteria:
Date
1.
Patient has organisms cultured from bone.
2.
Patient has evidence of osteomyelitis on gross anatomic or histopathologic exam.
3.
Patient has at least two of the following signs or symptoms with no other recognized cause: fever (> 38° C±), swelling*, pain or
tenderness*, heat*, or drainage*
AND at least one of the following:
a.
Organisms cultured from blood in a patient with imaging test evidence of infection
b.
Positive laboratory test on blood (e.g., antigen test, PCR)
c.
Imaging test evidence of infection (e.g., x-ray, CT scan, MRI, radiolabel scan [gallium, technetium, etc.])
* With no other recognized cause
± As documented in the medical record
Reporting instructions:

Report mediastinitis following cardiac surgery that is accompanied by osteomyelitis as SSI-MED rather than SSI-BONE.
Notes/Comments:
2015 CAMC BONE – Osteomyelitis 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)