Page 217 - policy and procedure infection control
P. 217
Policies and Procedures on Infection Control
Appendix B
B. MICROBIOLOGY REPORT (Include only the positive cultures relevant to NI)
No Date Specimen Date of Lab Result Type of Organism(s) Isolated
Sent Received Specimen
C. DEVICES USED BEFORE THE ONSET OF NOSOCOMIAL NFECTION
Date inserted
1. Indwelling urinary catheter …………………………
2. Mechanical ventilator …………………………
3. Tracheostomy …………………………
4. Central venous catheter …………………………
5. Arterial Lines ...……………………….
6. Peripheral venous line ...……………………….
7. Other drainage catheters ..………………………..
e.g EVD, Chest tube, etc ( Please Specify ) .……………………………
D. GENERAL PREDISPOSING RISK FACTORS
1. Underlying disease (Specify : ………………….…)
2. Immunosuppressive therapy (Specify : ………………….…)
3. Prolonged hospitalization > 2/52
4. Prematurity / Low Birth Weight
5. Others (Specify : ……………….……)
Name of person completing the form:_______________________________________________
Date:________________
Signature:___________________________________
204 Ministry of Health Malaysia
