INFECTION CONTROL INCIDENT REPORT

Facility Name
Complete this form on any resident if: Todays date _____________
there are signs and symptoms of infection OR
a culture is done OR
an antibiotic/antifungal is ordered OR
the resident is transferred to the hospital or expires due to a suspected infection

Residents name _______________________ Medical record number ________________

Signs and Symptoms (Check all that apply)

1. [ ] Breath sounds, abnormal : rales, 43. [ ] Other signs and symptoms of infection
rhonchi, wheezes, bronchial breathing Specify __________________
2. [ ] Change in functional status (ADLs) 44. [ ] Physician sees resident and diagnosis
3. [ ] Change in mental status (worsening) infection Site ______________
4. [ ] Conjunctival redness
5. [ ] Cough, dry Invasive devices
6. [ ] Cough, increased A. [ ] Urinary catheter
7. [ ] Cough, new B. [ ] Suprapubic catheter
8. [ ] Cough, productive C. [ ] Self intermittent catheterization
9. [ ] Diarrhea, loose or watery stool D. [ ] Assisted intermittent
10. [ ] Difficulty swallowing catheterization
11. [ ] Drainage, foul-smelling Site ______ E. [ ] Permanent intravenous catheter
12. [ ] Drainage, serous Site ___________ F. [ ] Peripheral intravenous catheter
13. [ ] Fever _____ oF or _____ oC G. [ ] PICC line
14. [ ]
Headache or eye pain H. [ ] Tracheostomy
15. [ ]
Heat Site _______________ I. [ ] J- or G-tube
16. [ ]
Hoarseness J. [ ] Nasogastic tube
17. [ ]
Hypotension (< 90 mm Hg systolic) K. [ ] Surgical drain
18. [ ]
Incontinence, new or worse L. [ ] Subcutaneous infusion
19. [ ]
Loss of appetite M. [ ] Other device
20. [ ]
Malaise Specify ________________
21. [ ]
Muscle aching
22. [ ]
Pink eye Culture
23. [ ]
Pleuritic chest pain Date obtained ______________
24. [ ]
Pus present Site _______________ Source ______________
25. [ ]
Rash, itching
26. [ ]
Rash, maculopapular X-ray
27. [ ]
Rash, vesicular Date obtained ______________
28. [ ]
Redness Site _______________ Type ______________
29. [ ]
Respiratory rate increased (> 25/min.)
30. [ ]
Runny nose Antibiotic/antifungal ordered
31. [ ]
Shortness of breath, new or worse Date ordered ______________
32. [ ]
Sneezing Name of medication ______________
33. [ ]
Sore throat
34. [ ]
Sputum, increased Patient Status
35. [ ]
Stuffy nose (nasal congestion) [ ] Remained in facility
36. [ ]
Swelling Site _______________
37. [ ]
Swollen or tender neck glands [ ] Admitted to hospital
38. [ ]
Tenderness Site _______________ Name of hospital ________________
39. [ ]
Urinating problems (new): pain, Date of admission _______________
frequency or urgency Reason for admission _____________
40. [ ] Urine, abnormal urinalysis
41. [ ] Urine, change in character, visual [ ] Expired
or smell
42. [ ] Vomiting, 3 or more episodes in 24
hours