CRBSI FOLLOW-UP FORM
PATIENT NAME: __________________________________ MID: _________________________
INITIAL BLOOD CULTURES
Date:__________________________ Physician: ______________________________
DAY 1
Reason: Surveillance Clinical
Shivering Fever Hypotension
Other: _____________________
Expected date of Preliminary results (Date of BC + 2 days): ____________________________
DAY 2 -3
If no prelim on Day 3: Call Microbiology Physician: ______________________ Lab Tech: ________________
Preliminary Results: Date: ______________________ Physician: _____________________________
C No Growth P No Growth C Gram + C P Gram + C Gram - P Gram -
C Yeast P Yeast
Expected date of Final results (Date of Prelim+ 2 days):
If no Final on Day 5: Call Microbiology Physician: _______________________ Lab Tech: _______________
DAY 4-6
Final Results: Date: _______________________ Physician: ______________________________
C No Growth P No Growth C Gram + C P Gram + C Gram - P Gram –
C Yeast P Yeast
Micro 1 Central: ____________________________ Micro 1 Peripheral: ________________________________
Micro 2 Central: ____________________________ Micro 2 Peripheral: ________________________________
7 DAYS REPEAT BLOOD CULTURES
Planned Date for 7 days repeat (initial BC date + 7 days): ________________________________
DAY 7
On Day 7: Request Repeat BC Physician: _______________________________
Expected date of Preliminary Results (Date of Repeat BC + 2 days): ______________________
DAY 8-9
If no Prelim on Day 9: Call Microbiology Physician: _______________________ Lab Tech: ________________
Preliminary Results: Date: _______________________ Physician: ______________________________
C No Growth P No Growth C Gram + C P Gram + C Gram - P Gram –
C Yeast P Yeast
Expected date of Final results (Date of Repeat Prelim+ 2 days):
If no Final on Day 11: Call Microbiology Physician: ______________________ Lab Tech: ________________
DAY 10-12
Final Results: Date: _______________________ Physician: ______________________________
C No Growth P No Growth C Gram + C P Gram + C Gram - P Gram –
C Yeast P Yeast
Micro 1 Central: ____________________________ Micro 1 Peripheral: _________________________________
Micro 2 Central: ____________________________ Micro 2 Peripheral: _________________________________
POST-TREATEMENT REPEAT BLOOD CULTURES
End of Treatment Date: ____________________
Planned Date for Post-treatment Repeat BC (End of TTT + 7 days): ________________________________
On Planned Date: Request Repeat BC Physician: _______________________________
Expected date of Preliminary Results (Date of Repeat BC + 2 days): ______________________
If no Prelim on Expected Date: Call Microbiology Physician: _________________ Lab Tech: _____________
Preliminary Results: Date: _______________________ Physician: ______________________________
C No Growth P No Growth C Gram + C P Gram + C Gram - P Gram –
C Yeast P Yeast
Expected date of Final results (Date of Repeat Prelim+ 2 days):
If no Final on Expected Date: Call Microbiology Physician: ___________________ Lab Tech: ____________
Final Results: Date: _______________________ Physician: ______________________________
C No Growth P No Growth C Gram + C P Gram + C Gram - P Gram –
C Yeast P Yeast
Micro 1 Central: _____________________________ Micro 1 Peripheral: __________________________________
Micro 2 Central: _____________________________ Micro 2 Peripheral: __________________________________
