Infection Progress Finding

NAME:
IC:
Diagnosis:
Co-morbid/Risk Factor:
Presenting illness:

Surgery
Operation procedure
Indication for surgery

Type of antibiotics
No Antibiotic Date Duration Remark
.
1.

Culture Summary
Date Type of Culture Finding Sensitivity Resistance

Date
ESR
CRP
TWBC
HbA1c
Investigation
ODI (Oswestry v.2)
Date
Section 1
Pain intensity
Section 2
Personal care
Section 3
Lifting
Section 4
Walking
Section 5
Sitting
Section 6
Standing
Section 7
Sleeping
Section 8
Sex Life(if applicable)
Section 9
Social life
Section 10
Travelling
Total score

VAS
Date
Lying
Movement
 Standing
Sitting
Imaging done

X-ray CT Scan MRI

Pre op
Post op
TCA

Patient’s Living Status

Working Medical leave Deceased

Duration: Date:
Caused of death: