HEALTHCARE-ASSOCIATED INFECTION SURVEILLANCE

PASIG CITY CHILDREN’S HOSPITAL (Child’s HOPE)

Industria St. Cor. Alcalde Jose St., Kapasigan, Pasig City

HEALTHCARE – ASSOCIATED INFECTION (HAI) SURVEILLANCE FORM

I. PROFILE
Patient’s Name ( Last, First, Middle Name ) AGE GENDER ROOM / BED No. PIN

Date of Admission Date of Trans – In / Out Date of Discharged Hospital Days

Reason for Admission Fever:

⎕ No ⎕ Yes: Started on:

_________________________
Lysed on: __________________________

Diagnosis:

II. DEVICES / USED

DEVICE Insertion Date Date Removed DEVICE Days / Period
Urinary Catheter

Central Line Catheter

Mechanical Ventilator

Others:

III. LABORATORIES AND CULTURES ( Include dates )

CBC Urine White Blood Cell Chest X-ray

Date Specimen Results

IV. ANTIBIOTIC REGIMEN V. (HAI) DIAGNOSIS

Duration
Antibiotics Used
Start Date End Date Catheter Associated Urinary Tract Infection ( CAUTI )
Ventilator Associated Pneumonia (VAP )
Centraline Associated Blood Stream Infection (CLABSI)

VI. OUTCOME
HAI Resolved
HAI improved but with loss of function
Pls. specify : ____________________________
Died secondary to HAI
Accomplished by:
__________________________________________________________________________________
Infection Control Officer
Signature Over Printed Name

PCCH – ICC – F – 004 REV. 00

 HEALTHCARE-ASSOCIATED INFECTION SURVEILLANCE

PASIG CITY CHILDREN’S HOSPITAL (Child’s HOPE)

Industria St. Cor. Alcalde Jose St., Kapasigan, Pasig City

PCCH – ICC – F – 004 REV. 00