DEPARTMENT OF HEALTH Procedure: General Infection

ILOCOS TRAINING AND REGIONAL MEDICAL CENTER Prevention & Control Procedure
City of San Fernando, La Union Form No.: MCC-IPCC-004-2
Tel: (072) 607-6418; (072) 607-6422; Telefax: (072) 700-3719
Revision No.: 2
Infection Prevention & Control Committee
itrmc.infectioncontrol@gmail.com Effectivity: February 2019
Note: Fill-up this form same time each day preferably during the closing of census at 12:00 midnight. May use printed or digital copy while filing up
this form.
This form will be the basis for device utilization rates and HAI rates.
PERIOD: JUNE 2021_ >48 HOURS
FORM 1 – HAI SURVEILLANCE
UNIT/AREA: ___MEDICal Total Discharges: ____
isolation 1st DEVICE DAYS MONITORING FOR HAI SURVEILLANCE Total Deaths: _14
Number of patients: Last day of the Previous Month ____________ First day of the Succeeding Month: _________
Number of Patients with/on:
Previous No. New Total No. Total No. Recorded
DAY Urinary Central line Ventilator /
of Patients Arrival Discharges of Patients by:
Catheter (s) Intubation
1 9 2 3 8 5 0 2
2 8 6 1 13 4 0 2
3 13 0 1 12 4 00 2
4 13 4 4 13 4 0 2
5 13 1 1 13 5 0 2
6 13 1 1 13 5 0 2
7 13 1 3 12 5 0 2
8 12 2 3 11 5 0 2
9 11 2 1 12 2 0 0
10 12 0 0 12 2 0 0
11 12 2 1 13 3 0 0
12 13 4 6 11 3 0 1
13 11 1 1 9 3 0 1
14 11 1 3 11 2 0 1
15 9 2 0 11 2 0 1
16 11 0 0 0 1 0 2
17 11 0 0 0 1 0 2
18 7 2 1 8 3 0 2
19 8 0 1 7 3 0 2
20 7 0 3 8 2 0 2
21 8 0 0 8 2 0 2
22 8 0 0 11 3 0 2
23 11 2 2 11 2 0 1
24 11 0 3 11 4 0 1
25 8 6 4 8 3 0 1
26 9 2 3 9 3 0 2
27 8 0 4 8 2 0 1
28 10 1 0 10 3 0 0
29 11 0 0 11 3 0 0
30
31
290 73 75 276 4 1 4

Reviewed by: (Nurse III) Noted by: (IPCN) Total I/MV Users for the month: ____4____ Remarks: (if
Total CL Users for the month: ____1_____ any)
Total IFC Users for the month: ______4____
Assurance of Confidentiality: Pursuant to the provisions of the Republic Act No. 10173 otherwise known as the Data Privacy Act of 2012, the
Hospital Infection Control Committee (HICC) of ITRMC shall information stated in this form with assurance of restricted access.