Name DOB Age Birthweight (gms) Test Period Unit Event Date M F (Neonates only) MR # Account # Medicare ID # Pt expire Admit date D/C date Yes No Admitting Diagnosis Attending / ID Consultant ICU Admit date ICU D/C date Culture date Pathogen(s) Culture Site Culture date Pathogen(s) Culture Site IAB- Intraabdominal infection, not specified elsewhere including gallbladder, bile ducts, liver (excluding viral hepatitis), spleen, pancreas, peritoneum, subphrenic or subdiaphragmatic space, or other intraabdominal tissue or area not specified elsewhere Intraabdominal infections must meet at least one of the following criteria: Date Patient has organisms cultured from abscess and/or purulent material from intraabdominal Patient has abscess or other evidence of intraabdominal infection on gross anatomic or histopathologic exam. Patient has at least two of the following signs or symptoms: fever (>38°C± ), nausea*, vomiting*, abdominal pain*, or jaundice of the following: AND at least one Organisms seen on culture or Gram stain of drainage or tissue obtained during invasive procedure or from an aseptically-placed drain (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage) Organisms cultured from blood and imaging test evidence of infection (e.g., ultrasound, CT scan, MRI, radiolabel scans [gallium, technetium, etc.] or on abdominal x-ray) * With no recognized cause ± As documented in the medical record Notes/Comments: of Events Event of Day RIT Unit Date Window Period Hospital Infection Date
Name DOB Age M F Birthweight (gms) (Neonates only) Test Period Unit Event Date MR # Account # Medicare ID # Pt expire Yes No Admit date D/C date Admitting Diagnosis Attending / ID Consultant ICU Admit date ICU D/C date Culture date Pathogen(s) Culture Site Culture date Pathogen(s) Culture Site IAB- Intraabdominal infection, not specified elsewhere including gallbladder, bile ducts, liver (excluding viral hepatitis), spleen, pancreas, peritoneum, subphrenic or subdiaphragmatic space, or other intraabdominal tissue or area not specified elsewhere Intraabdominal infections must meet at least one of the following criteria: Date Patient has organisms cultured from abscess and/or purulent material from intraabdominal Patient has abscess or other evidence of intraabdominal infection on gross anatomic or histopathologic exam. Patient has at least two of the following signs or symptoms: fever (>38°C± ), nausea*, vomiting*, abdominal pain*, or jaundice AND at least one of the following: Organisms seen on culture or Gram stain of drainage or tissue obtained during invasive procedure or from an aseptically-placed drain (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage) Organisms cultured from blood and imaging test evidence of infection (e.g., ultrasound, CT scan, MRI, radiolabel scans [gallium, technetium, etc.] or on abdominal x-ray) * With no recognized cause ± As documented in the medical record Notes/Comments: of Events Date Hospital Day Date of Event Infection Window Period RIT Unit
14_2015_IAB_Intraabdominal_Infection_Worksheet.docx