Communicating reason for isolation

Dear Dr. __________________________Your Patient__________________________________

Has been placed in the following isolation:
1. Contact Precautions: Gown and gloves for patient contact. Patient restrict to their rooms. Dedicated
equipment in room Level III MDRO
2. Modified Contact Precautions: For patients with MDROs. Good hand hygiene, clean equipment
thoroughly, patient may be cohorted and may leave their room. Level 1 and II MDRO
3. Droplet Precautions: Wear a mask for 3 feet or closer to patient. Patient must wear mask when leaving
the room. Restrict movement. Therapy at bedside unless absolutely necessary to take to gym.
Level I Precaution Low: MDRO in sputum but no cough, MDRO colonization, MDRO in urine but patient
continent, MDRO in nares.
Level II Precaution Medium: MDRO in sputum and pt has productive cough, MDRO in urine and patient is
incontinent, MDRO in wound but can be contained.
Level III Precaution High: Patients with active infection with MDRO who are not able to perform hand
hygiene, cover their cough or contain their secretions.
Initiated due to the following:
A. ____ History of MRSA or VRE per Hospital Data History as notified by Micro and / or Infection Control.
B. _____ Positive culture for ___________________Date of Culture_____________
C. _____History of _____________examples: (MRSA in previous 12 months, Hx TB)
D. _____ Based on presenting symptoms (Example: abscess, draining wound, decubitus, s/s TB, s/s flu,
diarrhea)
Nursing or Infection Control has done one or more of the following actions:
1. _____Isolation supplies. Obtain supplies/ cart and or box.
2. _____Label the door and chart: Use appropriate sticker.
3. _____Notification: Isolation precaution form in chart and signed by physician.
4. _____Educate patient and significant family members regarding isolation rational, purpose and
requirements including hand hygiene. Use isolation booklet to educate.
Form completed by: _____________________________________
Date: _________________ Time: ___________
Communication Sheet Only.
File in IC progress notes.
This form provides that missing link and prompts nursing when isolation initiated to follow thru with education
etc.
Debbie A. Clark RRT/MPH
Infection Preventionist
ext. 4864
Tallahassee, FL
Deborah.Clark2@Healthsouth.com