HOSPITAL ACQUIRED INFECTION SURVEILLANCE DATA FORM - SSI
Patient Name: MRN No: Age/Sex Location:
Department: Admitting Unit: DOA: Date of transfer to current location:
Provisional Diagnosis: Final Diagnosis:
Outcome: Transfer Out on: Left against medical advice on Discharged on: Expired on:
Type of surgery: Date of surgery:
DAILY MONITORING D-1 D-2 D-3 D-4 D-5 D-6 D-7 D-8 D-9 D-10
HAI DATE
Purulent Discharge at site
Pain Or Tenderness(Localized)
Localized Swelling
SSI Erythema
Increased local temperature(heat)
Abscess at site***
Surgeon’s Diagnosis(for superficial
SSI)
Microbiology Culture Report (Site Specific Culture)
Organism Antimicrobial Susceptibility
Date of Sample Collection Sample Colony Count
Isolated Report
Data Collected by Infection Control Nurse Data verified by Infection Control Officer
Name and Signature with date Name and Signature with Date
*** Defected by gross anatomical /histopathological examination /imaging test
INFECTION CONTROL DEPARTMENT
HOSPITAL ACQUIRED INFECTION SURVEILLANCE DATA FORM - SSI
SSI (SURGICAL SITE INFECTION) Reporting Criteria Date Of Event :
1 Patient had a surgery with in past 30 days Or Yes/No
Suregery with in 90 days if implant in placed Or breast, cardiac surgery Or herniorrhaphy
2 Wound class Clean Clean contaminated Contaminated Dirty Yes/No
(Tick
appropriate)
3 PATOS(Present At the time of Surgery) Visible pus/abscess at operation site; Documented in OT Note Yes/No
4 Any one of the Following:
Any one of the Following: Yes/No
1)Purulent drainage from superficial incision
SI-SSI ( Superficial 2) Positive Culture in aseptically obtained specimen from superficial incisional site
Incisional) 3) Superficial incision that is deliberately opened by the surgeon and culture not
performed, but patient has at least one of the following: a)Pain or Tenderness, b)
Localized swelling, c)Erythema Or d)Heat
4) Diagnosis of a superficial incisional SSI by the surgeon or attending Physician
Any one of the Following: Yes/No
1) Purulent drainage from Deep incision
DI-SSI (Deep 2) A deep incision that spontaneously dehisces, Or is deliberatley opened Or aspirated
Incisional) and culture is positive Or not perfomed and patient has at least one of the following;
Fever(>100.4F) Localized pain or Tenderness
3) Abscess Or other evidence of infection involving the deep incision that is detected on
gross anatomical or histopathologic exam, Or imaging test
Any one of the Following: Yes/No
1) Purulent drainage from drain through the Organ Or Space
Organ Space-SSI 2) Culture positive from an aseptically obtained fluid Or tissue in the organ/space
3) Abscess Or other evidence of infection involving the organ/space that is detected on
gross anatomical or histopathologic exam, Or imaging test
And meets at least one criterion for a specific organ/space infection site listed in NHSN
Data collected by Infection Control Nurse: Date verified by Infection Control officer:
Name and Signature with date: Name and Signature with date:
INFECTION CONTROL DEPARTMENT
