Active Surveillance Form for history .pdf

Active surveillance

1. PAKISTAN KIDNEY AND LIVER
INSTITUTE AND RESEARCH CENTER
ACTIVE SURVEILLANCE FORM
1
IPC F0040, Ver:02, ED:26-01-2023
Patient Name: ________________
MR#: _______________________
INVASIVE LINES
Date & Dept
Central line (Site, Insertion &
Removal)

IV Catheter (Site, Insertion &
Removal)

Arterial Catheter (Site, Insertion &
Removal)

ETT (Insertion & Removal)
Foley Catheter
Insertion & Removal



Bed Sore Stage (CA/HAI)
Antimicrobials (Dose & Route)
CLABSI/CRBSI Sign & Symptoms
TLC Or CRP
Temperature (max/Min) last 24 hrs
Observer Name: Gender
(M/F)
Bed/Room # Code status: Date of admission Date of
Discharge
Age: Transferred from: Transferred to Date of transfer

Diagnosis Consultant Name: Any surgery if yes
(specify)
Screen (base line cultures) if any HAI: (Yes/No)
(CLABSI, CAUTI, VAP
Patient status (Alive/Expired)

2. PAKISTAN KIDNEY AND LIVER
INSTITUTE AND RESEARCH CENTER
ACTIVE SURVEILLANCE FORM
2
IPC F0040, Ver:02, ED:26-01-2023
Patient Name: ________________
MR#: _______________________
Date & Dept
Hypotension (Max/Min) last 24 hrs
Blood/Tip CS
(organism + site)

Phlebitis (stage, CA/HA)
Mucositis (Stage, CA/HA)
CAUTI/UTI Sign & Symptoms
Color of Urine (Pyuria) Y/N
Suprapubic, Tenderness/Pain Y/N
Frequency (Y/N)
Urgency (Y/N)
Dysuria (Y/N)
Urine CS (Organism & site)
VAE/VAP Sign & symptoms
PEEP 0-5>
FIO2 %
New Abx changed
Purulent Respiratory secretions
+ve.

Pleural fluid/biopsy +ve
BAL/tracheal CS +ve