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SURGICAL SITE INFECTION SURVEILLANCE INFECTION FORM for AGGREGATED denominator data only Patient label PATIENT DATA Birthdate Sex M F // dd-mm-yyyy Admission number Admission date // dd-mm-yyyy Service / ward 1-3 SURGICAL INTERVENTION N Complete a new form for each operation max. 3 operations Date of operation // dd-mm-yyyy Surgeon 1. OR team Option Kwaliteitsdecreet Y N Procedure Code NNIS cat. Description ICD-9-CM. Wound class 1-4 9 unknown Contaminated/infected Y ASA score 1-5 9 unknown Duration of operation H Min hours and minutes 00. 00 unknown Laparo/endoscopy Y Elective Y Infection date // dd-mm-yyyy Infection site if CBGB Superficial incisional chest leg incision Deep incisional Organ/space Detected during Admission Secondary septicaemia Y Reintervention Y Post-discharge OPD SP GP R O N indicate Y only if reintervention is related to SSI Readmission Y Culture taken Y Microorganism code or name Type of specimen Comment Lab number WD WS XX PATIENT FOLLOW-UP Date of discharge/death // dd-mm-yyyy Status at discharge Alive Dead Optional LAM VS CBGB CBGC Always use the 4-digit ICD-9-CM code unless a 4th digit is not available. Detected post-discharge OPD outpatient department/clinic SP surgeon private consultation GP general practitioner/family doctor R hospital readmission O other. 3 operations Date of operation // dd-mm-yyyy Surgeon 1. OR team Option Kwaliteitsdecreet Y N Procedure Code NNIS cat. Description ICD-9-CM. Wound class 1-4 9 unknown Contaminated/infected Y ASA score 1-5 9 unknown Duration of operation H Min hours and minutes 00. Description ICD-9-CM. Wound class 1-4 9 unknown Contaminated/infected Y ASA score 1-5 9 unknown Duration of operation H Min hours and minutes 00. 00 unknown Laparo/endoscopy Y Elective Y Infection date // dd-mm-yyyy Infection site if CBGB Superficial incisional chest leg incision Deep incisional Organ/space Detected during Admission Secondary septicaemia Y Reintervention Y Post-discharge OPD SP GP R O N indicate Y only if reintervention is related to SSI Readmission Y Culture taken Y Microorganism code or name Type of specimen Comment Lab number WD WS XX PATIENT FOLLOW-UP Date of discharge/death // dd-mm-yyyy Status at discharge Alive Dead Optional LAM VS CBGB CBGC Always use the 4-digit ICD-9-CM code unless a 4th digit is not available. 00 unknown Laparo/endoscopy Y Elective Y Infection date // dd-mm-yyyy Infection site if CBGB Superficial incisional chest leg incision Deep incisional Organ/space Detected during Admission Secondary septicaemia Y Reintervention Y Post-discharge OPD SP GP R O N indicate Y only if reintervention is related to SSI Readmission Y Culture taken Y Microorganism code or name Type of specimen Comment Lab number WD WS XX PATIENT FOLLOW-UP Date of discharge/death // dd-mm-yyyy Status at discharge Alive Dead Optional LAM VS CBGB CBGC Always use the 4-digit ICD-9-CM code unless a 4th digit is not available. Detected post-discharge OPD outpatient department/clinic SP surgeon private consultation GP general practitioner/family doctor R hospital readmission O other.

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