Post-discharge Worksheet for Suspected SSI SAMPLE: [Insert [Insert Name Date] Ambulatory Surgery Center] Post-discharge Surgical Site Infection Surveillance Patient No Evidence Patient First Procedure Procedure Procedure Surgeon of SSI Last Name Name Date of Birth Gender ID Date Category Code Smith Roger 10/20/1944 F 27467 06/30/2018 COLO 0103 Greene Rachel 07/27/1949 F 27486 06/16/2018 COLO 0103 Blakeman Mark 12/01/1927 M 27497 06/30/2018 COLO 0103 Fields Rebecca 01/15/1960 F 27525 06/31/2018 COLO 0103 Hunter Sean 09/23/1933 M 27531 06/24/2018 COLO 0103 Mary 07/16/1970 F 06/09/2018 HYST 0103 Jones SeQuisha 06/29/1972 F 35015 06/02/2018 HYST 0103 Archin Latoya 09/03/1967 F 35016 06/07/2018 HYST 0103
Patient Last Name Patient First Name Date of Birth Gender Procedure ID Procedure Date Procedure Category Surgeon Code No Evidence of SSI Smith Roger 10/20/1944 F 27467 06/30/2018 COLO 0103 Greene Rachel 07/27/1949 F 27486 06/16/2018 COLO 0103 Blakeman Mark 12/01/1927 M 27497 06/30/2018 COLO 0103 Fields Rebecca 01/15/1960 F 27525 06/31/2018 COLO 0103 Hunter Sean 09/23/1933 M 27531 06/24/2018 COLO 0103 Mary 07/16/1970 F 06/09/2018 HYST 0103 Jones SeQuisha 06/29/1972 F 35015 06/02/2018 HYST 0103 Archin Latoya 09/03/1967 F 35016 06/07/2018 HYST 0103 SAMPLE: Post-discharge Worksheet for Suspected SSI [Insert Name Ambulatory Surgery Center] [Insert Date] Post-discharge Surgical Site Infection Surveillance
opc-ssi-post-discharge-toolkit-508.docx