JHH Infection Control Cardiac Surgery Surveillance

 
Last Name:___________________________      First Name:_________________________      Hx NO:______
Sex:   M       F                                                 Age(years): __________________                 Adm.Date:______
Disch Date: ____________________                 Culture Date: _________________                 SSI Site: _______
Sternum:
SVG:
Organism 1: __________           Sensitivity 1: _________         Organism 1:_________     Sensitivity 1:________ 
Organism 2: __________           Sensitivity 2: _________         Organism 2:_________     Sensitivity 2:________ 
Organism 3: __________           Sensitivity 3: _________         Organism 3:_________     Sensitivity 3:________ 
Surgery Date:________________         Sternum Depth:________________        SVG Depth: ________________
Surgery: ________________        Valve:  Y     N         SVG:  Y       N          IMA:  Y       N        Redo:  Y     N
Surgeon: ______________________    Assist1: _____________________     Assist2: _____________________
PA1: _____________________     PA2: _____________________   Anesthesiologist:______________________
ORRM:: _______________________           ASA:    1      2      3      4      5      E          Weight(kg): _________
OP Begin: ____________________  OP End: ____________________      Incision Time (minutes): __________
Shave/Clip/None:________________       ShaveSite:________________      s Bypass Time(minutes): __________
Antibiotics:
ABX1: ________________                       Time1: ________________                  AMT(g): : ________________
ABX2: ________________                       Time2: ________________                  AMT(g): : ________________
Diabetes:     Y     N                                        Insulin:     Y     N           s                         Smoker:     Y     N

Created by HEIC Dept. JHH (12/6/99)