Page 214 - policy and procedure infection control
P. 214
Policies and Procedures on Infection Control
Appendix B
KKM/NI/2007/1
CASE INFORMATION FORMAT
(Please complete separate form for each nosocomial infection case detected. Note that one
patient may have more than one nosocomial infection)
(Tick ( √ ) in the appropriate boxes)
Hospital:…...............……… Ward: ….......………… Dept/Unit:….........………. R/N:………...........…….
Patient Name: ………………………………………………….............. I/C New):…….........…………….
Age ………………… Sex:…...……………... Race:………........…… Date of Admission: …..........……....
Clinical Diagnosis on Admission:……………………….............................................................................…
Date of Nosocomial Infection Detected:………………………...................................................................…
Antibiotic Treatment: 1…................................................................................……………………………
2…................................................................................……………………………
3…................................................................................……………………………
4…................................................................................……………………………
A. TYPES OF NOSOCOMIAL INFECTIONS:
(refer to specific”case definitions”)
1. Urinary tract infection
2. Pneumonia
3. Surgical Wound Infection (For surgical wound infections, tick one of the boxes )
Superficial surgical site infection (SSI)
Deep incisional wound SSI
Organ / space SSI
4. Bacterimia
5. Clinical Sepsis
6. Others (Specify :…………………………….)
Ministry of Health Malaysia 203
