Include P12 V2 - HSPAHF04

HSPAHF04.CH

 #DEFINE STR0001 FWI18NLang("HSPAHF04","STR0001",1)
#DEFINE STR0002 FWI18NLang("HSPAHF04","STR0002",2)
#DEFINE STR0003 FWI18NLang("HSPAHF04","STR0003",3)
#DEFINE STR0004 FWI18NLang("HSPAHF04","STR0004",4)
#DEFINE STR0005 FWI18NLang("HSPAHF04","STR0005",5)
#DEFINE STR0006 FWI18NLang("HSPAHF04","STR0006",6)
#DEFINE STR0007 FWI18NLang("HSPAHF04","STR0007",7)
#DEFINE STR0008 FWI18NLang("HSPAHF04","STR0008",8)
#DEFINE STR0009 FWI18NLang("HSPAHF04","STR0009",9)
#DEFINE STR0010 FWI18NLang("HSPAHF04","STR0010",10)
#DEFINE STR0011 FWI18NLang("HSPAHF04","STR0011",11)
#DEFINE STR0012 FWI18NLang("HSPAHF04","STR0012",12)
#DEFINE STR0013 FWI18NLang("HSPAHF04","STR0013",13)
#DEFINE STR0014 FWI18NLang("HSPAHF04","STR0014",14)
#DEFINE STR0015 FWI18NLang("HSPAHF04","STR0015",15)
#DEFINE STR0016 FWI18NLang("HSPAHF04","STR0016",16)
#DEFINE STR0017 FWI18NLang("HSPAHF04","STR0017",17)
#DEFINE STR0018 FWI18NLang("HSPAHF04","STR0018",18)
#DEFINE STR0019 FWI18NLang("HSPAHF04","STR0019",19)
#DEFINE STR0020 FWI18NLang("HSPAHF04","STR0020",20)
#DEFINE STR0021 FWI18NLang("HSPAHF04","STR0021",21)
#DEFINE STR0022 FWI18NLang("HSPAHF04","STR0022",22)
#DEFINE STR0023 FWI18NLang("HSPAHF04","STR0023",23)
#DEFINE STR0024 FWI18NLang("HSPAHF04","STR0024",24)
#DEFINE STR0025 FWI18NLang("HSPAHF04","STR0025",25)
#DEFINE STR0026 FWI18NLang("HSPAHF04","STR0026",26)
#DEFINE STR0027 FWI18NLang("HSPAHF04","STR0027",27)
#DEFINE STR0028 FWI18NLang("HSPAHF04","STR0028",28)
#DEFINE STR0029 FWI18NLang("HSPAHF04","STR0029",29)
#DEFINE STR0030 FWI18NLang("HSPAHF04","STR0030",30)
#DEFINE STR0031 FWI18NLang("HSPAHF04","STR0031",31)
#DEFINE STR0032 FWI18NLang("HSPAHF04","STR0032",32)
#DEFINE STR0033 FWI18NLang("HSPAHF04","STR0033",33)
#DEFINE STR0034 FWI18NLang("HSPAHF04","STR0034",34)
#DEFINE STR0035 FWI18NLang("HSPAHF04","STR0035",35)
#DEFINE STR0036 FWI18NLang("HSPAHF04","STR0036",36)
#DEFINE STR0037 FWI18NLang("HSPAHF04","STR0037",37)
#DEFINE STR0038 FWI18NLang("HSPAHF04","STR0038",38)
#DEFINE STR0039 FWI18NLang("HSPAHF04","STR0039",39)
#DEFINE STR0040 FWI18NLang("HSPAHF04","STR0040",40)
#DEFINE STR0041 FWI18NLang("HSPAHF04","STR0041",41)
#DEFINE STR0042 FWI18NLang("HSPAHF04","STR0042",42)
#DEFINE STR0043 FWI18NLang("HSPAHF04","STR0043",43)
#DEFINE STR0044 FWI18NLang("HSPAHF04","STR0044",44)
#DEFINE STR0045 FWI18NLang("HSPAHF04","STR0045",45)
#DEFINE STR0046 FWI18NLang("HSPAHF04","STR0046",46)
#DEFINE STR0047 FWI18NLang("HSPAHF04","STR0047",47)
#DEFINE STR0048 FWI18NLang("HSPAHF04","STR0048",48)
#DEFINE STR0049 FWI18NLang("HSPAHF04","STR0049",49)
#DEFINE STR0050 FWI18NLang("HSPAHF04","STR0050",50)
#DEFINE STR0051 FWI18NLang("HSPAHF04","STR0051",51)
#DEFINE STR0052 FWI18NLang("HSPAHF04","STR0052",52)
#DEFINE STR0053 FWI18NLang("HSPAHF04","STR0053",53)
#DEFINE STR0054 FWI18NLang("HSPAHF04","STR0054",54)
#DEFINE STR0055 FWI18NLang("HSPAHF04","STR0055",55)
#DEFINE STR0056 FWI18NLang("HSPAHF04","STR0056",56)
#DEFINE STR0057 FWI18NLang("HSPAHF04","STR0057",57)
#DEFINE STR0058 FWI18NLang("HSPAHF04","STR0058",58)
#DEFINE STR0059 FWI18NLang("HSPAHF04","STR0059",59)
#DEFINE STR0060 FWI18NLang("HSPAHF04","STR0060",60)
#DEFINE STR0061 FWI18NLang("HSPAHF04","STR0061",61)
#DEFINE STR0062 FWI18NLang("HSPAHF04","STR0062",62)
#DEFINE STR0063 FWI18NLang("HSPAHF04","STR0063",63)
#DEFINE STR0064 FWI18NLang("HSPAHF04","STR0064",64)
#DEFINE STR0065 FWI18NLang("HSPAHF04","STR0065",65)
#DEFINE STR0066 FWI18NLang("HSPAHF04","STR0066",66)
#DEFINE STR0067 FWI18NLang("HSPAHF04","STR0067",67)
#DEFINE STR0068 FWI18NLang("HSPAHF04","STR0068",68)
#DEFINE STR0069 FWI18NLang("HSPAHF04","STR0069",69)
#DEFINE STR0070 FWI18NLang("HSPAHF04","STR0070",70)
#DEFINE STR0071 FWI18NLang("HSPAHF04","STR0071",71)
#DEFINE STR0072 FWI18NLang("HSPAHF04","STR0072",72)
#DEFINE STR0073 FWI18NLang("HSPAHF04","STR0073",73)
#DEFINE STR0074 FWI18NLang("HSPAHF04","STR0074",74)
#DEFINE STR0075 FWI18NLang("HSPAHF04","STR0075",75)
#DEFINE STR0076 FWI18NLang("HSPAHF04","STR0076",76)
#DEFINE STR0077 FWI18NLang("HSPAHF04","STR0077",77)
#DEFINE STR0078 FWI18NLang("HSPAHF04","STR0078",78)
#DEFINE STR0079 FWI18NLang("HSPAHF04","STR0079",79)
#DEFINE STR0080 FWI18NLang("HSPAHF04","STR0080",80)
#DEFINE STR0081 FWI18NLang("HSPAHF04","STR0081",81)
#DEFINE STR0082 FWI18NLang("HSPAHF04","STR0082",82)
#DEFINE STR0083 FWI18NLang("HSPAHF04","STR0083",83)
#DEFINE STR0084 FWI18NLang("HSPAHF04","STR0084",84)
#DEFINE STR0085 FWI18NLang("HSPAHF04","STR0085",85)
#DEFINE STR0086 FWI18NLang("HSPAHF04","STR0086",86)
#DEFINE STR0087 FWI18NLang("HSPAHF04","STR0087",87)
#DEFINE STR0088 FWI18NLang("HSPAHF04","STR0088",88)
#DEFINE STR0089 FWI18NLang("HSPAHF04","STR0089",89)
#DEFINE STR0090 FWI18NLang("HSPAHF04","STR0090",90)
#DEFINE STR0091 FWI18NLang("HSPAHF04","STR0091",91)
#DEFINE STR0092 FWI18NLang("HSPAHF04","STR0092",92)
#DEFINE STR0093 FWI18NLang("HSPAHF04","STR0093",93)
#DEFINE STR0094 FWI18NLang("HSPAHF04","STR0094",94)
#DEFINE STR0095 FWI18NLang("HSPAHF04","STR0095",95)
#DEFINE STR0096 FWI18NLang("HSPAHF04","STR0096",96)
#DEFINE STR0097 FWI18NLang("HSPAHF04","STR0097",97)
#DEFINE STR0098 FWI18NLang("HSPAHF04","STR0098",98)
#DEFINE STR0099 FWI18NLang("HSPAHF04","STR0099",99)
#DEFINE STR0100 FWI18NLang("HSPAHF04","STR0100",100)
#DEFINE STR0101 FWI18NLang("HSPAHF04","STR0101",101)
#DEFINE STR0102 FWI18NLang("HSPAHF04","STR0102",102)
#DEFINE STR0103 FWI18NLang("HSPAHF04","STR0103",103)
#DEFINE STR0104 FWI18NLang("HSPAHF04","STR0104",104)
#DEFINE STR0105 FWI18NLang("HSPAHF04","STR0105",105)
#DEFINE STR0106 FWI18NLang("HSPAHF04","STR0106",106)
 

HSPAHF04_EN.TRES

 0001#STR0001#ALL#FORM OF COMMISSION FOR CONTROL OF HOSPITAL INFECTION
0002#STR0002#ALL#C. C. H. I.
0003#STR0003#ALL#Male     
0004#STR0004#ALL#Female  
0005#STR0005#ALL#HOSPITAL INFECTION CONTROL REPORT
0006#STR0006#ALL#1-IDENTIFICATION
0007#STR0007#ALL#NAME..: 
0008#STR0008#ALL#SEX: 
0009#STR0009#ALL#AGE:   
0010#STR0010#ALL#ETHINIC ORIGIN: 
0011#STR0011#ALL#REGISTRATION: 
0012#STR0012#ALL#SECTOR: 
0013#STR0013#ALL#HEALTHCARE PLAN: 
0014#STR0014#ALL#ATTEND. TYPE:   
0015#STR0015#ALL#ROOM:   
0016#STR0016#ALL#N.B. Weight at birth:   (  ) < 1.500g     (  ) 1.501g to 2.500g    (  ) > 2.500g
0017#STR0017#ALL#2- HOSPITALIZATION DATA   Previous Admi. in this Hospital   Yes(  )  No(  )
0018#STR0018#ALL#2- HOSPITALIZATION DETAILS
0019#STR0019#ALL#2.1.PRIMARY DIAGNOSIS:______________________________________________________
0020#STR0020#ALL#2.2.SECONDARY DIAGNOSIS________________________________________________
0021#STR0021#ALL#2.3.SURGERY:___________________________________________________________________
0022#STR0022#ALL#Surgery importance  Classification of surgery               Status              
0023#STR0023#ALL#2.3.1.BIG     ( )   2.3.4 CLEAN                      ( )  2.3.8  ELECTIVE    ( )
0024#STR0024#ALL#2.3.2. AVERAGE( )   2.3.5 POTENTIALLY CONTAMINATED   ( )  2.3.9  URGENCY     ( )
0025#STR0025#ALL#2.3.3.SMALL   ( )   2.3.6 CONTAMINATED               ( )  2.3.10 EMERGENCY   ( )
0026#STR0026#ALL#                    2.3.7 INFECTED                  ( )                        
0027#STR0027#ALL#3- DIAGNOSTIC/THERAPEUTIC PROCEDURES
0028#STR0028#ALL#3.1.ANTIMICROBIAL      ( ) 3.8. DRAIN               ( )  3.15.LUMBAR FUNCTION( )
0029#STR0029#ALL#3.2.BREATHING          ( ) 3.9. ENDOSCOPY           ( )  3.16.PLEURAL FUNCT. ( )
0030#STR0030#ALL#3.3.BIOPSY             ( ) 3.10.ENDOTRACHIAL TUBIN. ( )  3.17.MECHANI RESP.  ( )
0031#STR0031#ALL#3.4.VENOUS CATHETER    ( ) 3.11.HEMODIALYSIS        ( )  3.18.VENOUS THERAPY ( )
0032#STR0032#ALL#3.5.VESICAL CATHETER   ( ) 3.12.NEBULIZATION        ( )  3.19.TRACHEOSTOMY  ( )
0033#STR0033#ALL#3.6.CORTICOID         ( ) 3.13.PARENTERAL NUTR.     ( )  3.20.BLOOD TRANSF.  ( )
0034#STR0034#ALL#3.7.PERITONIAL DIALYSIS( ) 3.14.PARACENTESIS        ( )  3.21.OTHERS         ( )
0035#STR0035#ALL#Note (S)=Uninfected, (A)= Infection before procedure, (D) after procedure 
0036#STR0036#ALL#4-MICROBIOLOGICAL EXAMS: CULTURE( ) CULTURE w/ANTIBIOGRAM( ) BACTERIOSCOPE( )
0037#STR0037#ALL#4-MICROBIOLOGICAL EXAMS: 
0038#STR0038#ALL#4.1.SECRECTIONS    ( )     4.3.URINE         ( )       4.5.LIQUOR            ( )
0039#STR0039#ALL#4.2.BLOOD          ( )     4.4.FECES         ( )       4.6.OTHERS            ( )
0040#STR0040#ALL#                                                       4.7.NOT DONE          ( )
0041#STR0041#ALL#5-DATA RELATING TO INFECTION
0042#STR0042#ALL#TYPOGRAPHIC LOCATION       | ON HOSPITAL. | Aft. 72Hs | After Dis |MICROORG.ISOLATED
0043#STR0043#ALL#5.1. CARDIOVASCULAR    ( ) |    ( )    |    ( )    |    ( )    |
0044#STR0044#ALL#5.2. SURGICAL          ( ) |    ( )    |    ( )    |    ( )    |
0045#STR0045#ALL#5.3. UMBILICAL COLON    ( ) |    ( )    |    ( )    |    ( )    |
0046#STR0046#ALL#5.4. CUTANEOUS         ( ) |    ( )    |    ( )    |    ( )    |
0047#STR0047#ALL#5.5. GASTRO INTESTINAL ( ) |    ( )    |    ( )    |    ( )    |
0048#STR0048#ALL#5.6. GENITAL           ( ) |    ( )    |    ( )    |    ( )    |
0049#STR0049#ALL#5.7. OCULAR            ( ) |    ( )    |    ( )    |    ( )    |
0050#STR0050#ALL#5.8. OSTEO-ARTICULAR   ( ) |    ( )    |    ( )    |    ( )    |
0051#STR0051#ALL#5.9. AUDITORY          ( ) |    ( )    |    ( )    |    ( )    |
0052#STR0052#ALL#5.10.PUERPERAL         ( ) |    ( )    |    ( )    |    ( )    |
0053#STR0053#ALL#5.11.SEPTICEMIA      ( ) |    ( )    |    ( )    |    ( )    |
0054#STR0054#ALL#5.12.INF. RESP.TREAT   ( ) |    ( )    |    ( )    |    ( )    |
0055#STR0055#ALL#5.13.SUP. RESP.TREAT   ( ) |    ( )    |    ( )    |    ( )    |
0056#STR0056#ALL#5.14.URINARY          ( ) |    ( )    |    ( )    |    ( )    |
0057#STR0057#ALL#5.15.OTHERS            ( ) |    ( )    |    ( )    |    ( )    |
0058#STR0058#ALL#6- ADMINISTRATION OF ANTIBIOTIC
0059#STR0059#ALL#6.1.YES  (  )     NO (  )
0060#STR0060#ALL#6.2.ANTIMICROBIAL(S) USED:___________________________________________
0061#STR0061#ALL#6.3.CLINICAL PROPHYLATIC (  )             SURGICAL  (  )
0062#STR0062#ALL#6.4.THERAPEUTIC ACCORDING TO CULTURE AND ANTIBIOGRAM (  )        EMPIRIC  (  )
0063#STR0063#ALL#7- CONDITIONS OF EXIT
0064#STR0064#ALL#7.1.CURED   (  )           7.2.IMPROVED   (  )        7.3.UNCHANGED   (  )
0065#STR0065#ALL#Discharge Dt ____/____/____
0066#STR0066#ALL#8- DISCHARGE TP
0067#STR0067#ALL#       (  ) DOCTOR INITIATIVE    (  ) TRANSFER           (  ) UPON REQUEST      
0068#STR0068#ALL#       (  ) INDISCIPLINE         (  ) ABANDONED          (  ) DEATH             
0069#STR0069#ALL#                                                         (  ) DEATH BY INFECTION
0070#STR0070#ALL#9- ASSISTANT DOCTOR:___________________  SIG._________________  SMB:___________
0071#STR0071#ALL#   ASSISTANT NURSE:___________________  SIG._________________  COREN:_________
0072#STR0072#ALL#10- BACTERIA
0073#STR0073#ALL#10.1.Acinetobacter SP                10.24.Pseudomonas SP                       
0074#STR0074#ALL#10.2.Alcaligenes SP                     10.25.Pseudomonas Aeruginosa            
0075#STR0075#ALL#10.3.Bordetella SP                      10.26.Salmonella SP                     
0076#STR0076#ALL#10.4.Citrobacter SP                     10.27.Salmonella Enteridis              
0077#STR0077#ALL#10.5.Clostridium SP                     10.28.Salmodella Typi                   
0078#STR0078#ALL#10.6.Corynebacterium Difteriae          10.29.Serratia SP                       
0079#STR0079#ALL#10.7.Edwardsiella                       10.30.Shigella SP                       
0080#STR0080#ALL#10.8.Escherichia Coli                   10.31.Shigella Dysenteriae (Sub Grupo A)
0081#STR0081#ALL#10.9.E. Coli. Enteroinvasora            10.32.Shigella Boydii (Sub Grupo C)     
0082#STR0082#ALL#10.10.E.Coli. EnteroPatog�nico          10.33.Shigella Flexneri (Sub Grupo B)   
0083#STR0083#ALL#10.11.EnteroBacter SP                   10.34.Shigella Sonnei (Sub Grupo D)     
0084#STR0084#ALL#10.12.Haemophilus                    10.35.Staphylococcus Auraus                
0085#STR0085#ALL#10.13.Klebsiella                     10.36.Staphylococcus Epidemidis            
0086#STR0086#ALL#10.14.Lactobacillus SP                  10.37.Staphylococcus SaproPhyticus      
0087#STR0087#ALL#10.15.Listeria Monocytogenes            10.38.Staphylococcus SP                 
0088#STR0088#ALL#10.16.Myco Bacterium SP              10.39.Streptococcus SP                     
0089#STR0089#ALL#10.17.Neisseria Meningitidis            10.40.Streptococcus - nao Hemol�tico    
0090#STR0090#ALL#10.18.Neisseria Gonoraheae              10.41.Streptococcus Virindas            
0091#STR0091#ALL#10.19.Proteus SP                        10.42.Streptococcus Beta Hemolitico (A) 
0092#STR0092#ALL#10.20.Proteus Morganii                  10.43.Streptococcus Beta Hemolitico     
0093#STR0093#ALL#10.21.Proteus Rettgeri               10.44.Streptococcus Fecalis                
0094#STR0094#ALL#10.22.Proteus Vulgaris                  10.45.Streptococcus Pneumoniea          
0095#STR0095#ALL#10.23.Providencia SP                    10.46.Outros                            
0096#STR0096#ALL#11- VIRUS
0097#STR0097#ALL#11.1.Hepatitis A virus (  ) 11.3.Hepatitis non A non B Virus 11.5.Others ( )
0098#STR0098#ALL#11.2.Hepatitis B virus (  ) 11.4.Virus HTLV 3                                 
0099#STR0099#ALL#12- FUNGI
0100#STR0100#ALL#12.1.Candida Albicans    (  ) 12.3.Criptococcus Neoformans      12.5.Others (  )
0101#STR0101#ALL#12.2.Candida Others      (  ) 12.4.Cryptococcus SP                              
0102#STR0102#ALL#13- INFECTION TYPE
0103#STR0103#ALL#    (  ) Community infection       (  ) There was no infection      
0104#STR0104#ALL#    (  ) Hospital infection        (  ) Infection from other hospital*
0105#STR0105#ALL#* SPECIFY THE HOSPITAL AND TOPOGRAPHY OF INFECTION
0106#STR0106#ALL#PLAN:   
 

HSPAHF04_ES.TRES

 0001#STR0001#ALL#FORMULARIO DE COMISION DE CONTROL DE INFECCION HOSPITALAR
0002#STR0002#ALL#C. C. I. H.
0003#STR0003#ALL#Masculino
0004#STR0004#ALL#Femenino
0005#STR0005#ALL#INFORME DE CONTROL DE INFECCION HOSPITALARIA
0006#STR0006#ALL#1- IDENTIFICACION
0007#STR0007#ALL#NOMBRE..: 
0008#STR0008#ALL#SEXO:
0009#STR0009#ALL#EDAD: 
0010#STR0010#ALL#COLOR: 
0011#STR0011#ALL#REGISTRO: 
0012#STR0012#ALL#SECTOR: 
0013#STR0013#ALL#CONVENIO: 
0014#STR0014#ALL#TIPO ATENCION: 
0015#STR0015#ALL#HABITACION: 
0016#STR0016#ALL#R .N. Peso al nacer:    (  ) < 1.500g      (  ) 1.501g a 2.500g    (  ) > 2.500g
0017#STR0017#ALL#2- DATOS DE LA HOSPITALIZACION  Inter. Anterior en este Hosp.   Si(  )   No(  )
0018#STR0018#ALL#2- DATOS DE HOSPITALIZACION
0019#STR0019#ALL#2.1.DIAGNOSTICO PRINCIPAL:______________________________________________________
0020#STR0020#ALL#2.2.DIAGNOSTICO(S) SECUNDARIO(S)________________________________________________
0021#STR0021#ALL#2.3.CIRUGIA:____________________________________________________________________
0022#STR0022#ALL#Tipo de Cirugia     Clasificacion de la cirurgia            Situacion           
0023#STR0023#ALL#2.3.1.GRANDE  ( )   2.3.4 LIMPIA                     ( )  2.3.8  ELECTIVA    ( )
0024#STR0024#ALL#2.3.2. MEDIANA( )   2.3.5 POTENCIALMETE CONTAMINADA  ( )  2.3.9  URGENCIA    ( )
0025#STR0025#ALL#2.3.3.PEQUENA ( )   2.3.6 CONTAMINADA                ( )  2.3.10 EMERGENCIA  ( )
0026#STR0026#ALL#                    2.3.7 INFECTADA                  ( )                        
0027#STR0027#ALL#3- PROCEDIMIENTOS DIAGNOSTICOS/TERAPEUTICOS
0028#STR0028#ALL#3.1.ANTIMICROBIANO     ( ) 3.8. DRENOS              ( )  3.15.FUNCION LOMBAR ( )
0029#STR0029#ALL#3.2.ASPIRACION         ( ) 3.9. ENDOSCOPIA          ( )  3.16.FUNCION PLEURAL( )
0030#STR0030#ALL#3.3.BIOPSIA            ( ) 3.10.ENTUB. ENDOTRAQUEAL ( )  3.17.RESP. MECANICO ( )
0031#STR0031#ALL#3.4.CATETER VENOSO     ( ) 3.11.HEMODIALISIS         ( )  3.18.TERAPIA VENOSA ( )
0032#STR0032#ALL#3.5.CATETER VESICAL    ( ) 3.12.NEBULIZACION         ( )  3.19.TRAQUEOTOMIA  ( )
0033#STR0033#ALL#3.6.CORTICOIDE         ( ) 3.13.NUTR.PARENTERAL     ( )  3.20.TRANSF.SANGRE  ( )
0034#STR0034#ALL#3.7.DIALISIS PERITONIAL ( ) 3.14.PARACENTESIS         ( )  3.21.OTROS         ( )
0035#STR0035#ALL#Anotar (S)=Sin infeccion, (A)= Infeccion antes del procedimiento, (D) despues procedimiento 
0036#STR0036#ALL#4-EXAMENES MICROBIOLOGICOS: CULTURA( ) CULTURA c/ANTIBIOGRAMA( ) BACTERIOSCOPIA( )
0037#STR0037#ALL#4-EXAMENES MICROBIOLOGICOS:
0038#STR0038#ALL#4.1.SECRECIONES    ( )     4.3.ORINA         ( )       4.5.LCR               ( )
0039#STR0039#ALL#4.2.SANGRE         ( )     4.4.HECES         ( )       4.6.OTROS            ( )
0040#STR0040#ALL#                                                       4.7.NO REALIZO      ( )
0041#STR0041#ALL#5-DATOS REFERENTES A INFECCION
0042#STR0042#ALL#LOCALIZACION TIPOGRAFICA    | EN LA INTER. | Despues 72Hs | Despus Alta |MICROORG.ISLADO
0043#STR0043#ALL#5.1. CARDIOVASCULAR    ( ) |    ( )    |    ( )    |    ( )    |
0044#STR0044#ALL#5.2. QUIRURGICA        ( ) |    ( )    |    ( )    |    ( )    |
0045#STR0045#ALL#5.3. COLO UMBILICAL    ( ) |    ( )    |    ( )    |    ( )    |
0046#STR0046#ALL#5.4. CUTANEA           ( ) |    ( )    |    ( )    |    ( )    |
0047#STR0047#ALL#5.5. GASTRO INTESTINAL ( ) |    ( )    |    ( )    |    ( )    |
0048#STR0048#ALL#5.6. GENITAL           ( ) |    ( )    |    ( )    |    ( )    |
0049#STR0049#ALL#5.7. OCULAR            ( ) |    ( )    |    ( )    |    ( )    |
0050#STR0050#ALL#5.8. OSTEO-ARTICULAR   ( ) |    ( )    |    ( )    |    ( )    |
0051#STR0051#ALL#5.9. OIDO            ( ) |    ( )    |    ( )    |    ( )    |
0052#STR0052#ALL#5.10.PUERPERAL         ( ) |    ( )    |    ( )    |    ( )    |
0053#STR0053#ALL#5.11.SEPTICEMIA      ( ) |    ( )    |    ( )    |    ( )    |
0054#STR0054#ALL#5.12.TRACTO RESP.INF.  ( ) |    ( )    |    ( )    |    ( )    |
0055#STR0055#ALL#5.13.TRACTO RESP.SUP.   ( ) |    ( )    |    ( )    |    ( )    |
0056#STR0056#ALL#5.14.URINARIA          ( ) |    ( )    |    ( )    |    ( )    |
0057#STR0057#ALL#5.15.OTRAS            ( ) |    ( )    |    ( )    |    ( )    |
0058#STR0058#ALL#6- USO DE ANTIBIOTICO
0059#STR0059#ALL#6.1.SI   (  )     NO  (  )
0060#STR0060#ALL#6.2.ANTIMICROBIANO(S) UTILIZADO(S):___________________________________________
0061#STR0061#ALL#6.3.PROFILACTICO CLINICO (  )             QUIRURGICO (  )
0062#STR0062#ALL#6.4.TERAPEUTICO DE ACUERDO CON LA CULTURA Y ANTIBIOGRAMA (  )        EMPIRICO (  )
0063#STR0063#ALL#7- CONDICIONES DE SALIDAS
0064#STR0064#ALL#7.1.CURADO  (  )           7.2.MEJORADO   (  )        7.3.INALTERADO  (  )
0065#STR0065#ALL#Fecha de Alta ____/____/____
0066#STR0066#ALL#8- TIPO DE ALTA
0067#STR0067#ALL#       (  ) INICIATIVA MEDICA    (  ) TRANSFERENCIA      (  ) A PEDIDO          
0068#STR0068#ALL#       (  ) INDISCIPLINA         (  ) ABANDONO           (  ) OBITO             
0069#STR0069#ALL#                                                         (  ) MUERTE POR INFECCION
0070#STR0070#ALL#9- MEDICO ASISTENTE:____________________  FIRMA________________  CRM:___________
0071#STR0071#ALL#   EMFER. ASISTENTE:____________________  FIRMA________________  COREN:_________
0072#STR0072#ALL#10- BACTERIAS
0073#STR0073#ALL#10.1.Acinetobacter SP                10.24.Pseudomonas SP                       
0074#STR0074#ALL#10.2.Alcaligenes SP                     10.25.Pseudomonas Aeruginosa            
0075#STR0075#ALL#10.3.Bordetella SP                      10.26.Salmonella SP                     
0076#STR0076#ALL#10.4.Citrobacter SP                     10.27.Salmonella Enteridis              
0077#STR0077#ALL#10.5.Clostridium SP                     10.28.Salmodella Typi                   
0078#STR0078#ALL#10.6.Corynebacterium Difteriae          10.29.Serratia SP                       
0079#STR0079#ALL#10.7.Edwardsiella                       10.30.Shigella SP                       
0080#STR0080#ALL#10.8.Escherichia Coli                   10.31.Shigella Dysenteriae (Sub Grupo A)
0081#STR0081#ALL#10.9.E. Coli. Enteroinvasora            10.32.Shigella Boydii (Sub Grupo C)     
0082#STR0082#ALL#10.10.E.Coli. EnteroPatog�nico          10.33.Shigella Flexneri (Sub Grupo B)   
0083#STR0083#ALL#10.11.EnteroBacter SP                   10.34.Shigella Sonnei (Sub Grupo D)     
0084#STR0084#ALL#10.12.Haemophilus                    10.35.Staphylococcus Auraus                
0085#STR0085#ALL#10.13.Klebsiella                     10.36.Staphylococcus Epidemidis            
0086#STR0086#ALL#10.14.Lactobacillus SP                  10.37.Staphylococcus SaproPhyticus      
0087#STR0087#ALL#10.15.Listeria Monocytogenes            10.38.Staphylococcus SP                 
0088#STR0088#ALL#10.16.Myco Bacterium SP              10.39.Streptococcus SP                     
0089#STR0089#ALL#10.17.Neisseria Meningitidis            10.40.Streptococcus - nao Hemol�tico    
0090#STR0090#ALL#10.18.Neisseria Gonoraheae              10.41.Streptococcus Virindas            
0091#STR0091#ALL#10.19.Proteus SP                        10.42.Streptococcus Beta Hemolitico (A) 
0092#STR0092#ALL#10.20.Proteus Morganii                  10.43.Streptococcus Beta Hemolitico     
0093#STR0093#ALL#10.21.Proteus Rettgeri               10.44.Streptococcus Fecalis                
0094#STR0094#ALL#10.22.Proteus Vulgaris                  10.45.Streptococcus Pneumoniea          
0095#STR0095#ALL#10.23.Providencia SP                    10.46.Outros                            
0096#STR0096#ALL#11- VIRUS
0097#STR0097#ALL#11.1.Virus A de Hepatitis (  ) 11.3.Virus no A no B de Hepatite 11.5.Otros ( )
0098#STR0098#ALL#11.2.Virus B de Hepatitis (  ) 11.4.Virus HTLV 3                                 
0099#STR0099#ALL#12- HONGOS
0100#STR0100#ALL#12.1.Candida Albicans    (  ) 12.3.Criptococcus Neoformans      12.5.Otros (  )
0101#STR0101#ALL#12.2.Candida Otras      (  ) 12.4.Criptococcus SP                              
0102#STR0102#ALL#13- TIPO DE INFECCION
0103#STR0103#ALL#    (  ) Infeccion Comunitaria      (  ) No Hubo Infeccion          
0104#STR0104#ALL#    (  ) Infeccion Hospitalaria       (  ) Infeccion de Otro Hospital *
0105#STR0105#ALL#* ESPECIFICAR EL HOSPITAL Y LA TOPOGRAFIA DE LA INFECCION
0106#STR0106#ALL#PLAN:  
 

HSPAHF04_PT-BR.TRES

 0001#STR0001#ALL#FORMULARIO DE COMISSAO DE CONTROLE DE INFEC��O HOSPITALAR
0002#STR0002#ALL#C. C. I. H.
0003#STR0003#ALL#Masculino
0004#STR0004#ALL#Feminino
0005#STR0005#ALL#FOLHA DE CONTROLE DE INFECCAO HOSPITLAR
0006#STR0006#ALL#1- IDENTIFICACAO
0007#STR0007#ALL#NOME..: 
0008#STR0008#ALL#SEXO:
0009#STR0009#ALL#IDADE: 
0010#STR0010#ALL#COR: 
0011#STR0011#ALL#REGISTRO: 
0012#STR0012#ALL#SETOR: 
0013#STR0013#ALL#CONVENIO: 
0014#STR0014#ALL#TP ATENDIMENTO: 
0015#STR0015#ALL#QUARTO: 
0016#STR0016#ALL#R.N. Peso ao Nascer:    (  ) < 1.500g      (  ) 1.501g a 2.500g    (  ) > 2.500g
0017#STR0017#ALL#2- DADOS DA HOSPITALIZACAO      Inter.Anterior neste Hospital   Sim(  )  Nao(  )
0018#STR0018#ALL#2- DADOS DA HOSPITALIZACAO
0019#STR0019#ALL#2.1.DIAGNOSTICO PRINCIPAL:______________________________________________________
0020#STR0020#ALL#2.2.DIAGNOSTICO(S) SECUND�RIO(S)________________________________________________
0021#STR0021#ALL#2.3.CIRURGIA:___________________________________________________________________
0022#STR0022#ALL#Porte Cirurgia      Classificacao da Cirurgia               Situacao            
0023#STR0023#ALL#2.3.1.GRANDE  ( )   2.3.4 LIMPA                      ( )  2.3.8  ELETIVA     ( )
0024#STR0024#ALL#2.3.2. MEDIANA( )   2.3.5 POTENCIALMETE CONTAMINADA  ( )  2.3.9  URGENCIA    ( )
0025#STR0025#ALL#2.3.3.PEQUENA ( )   2.3.6 CONTAMINADA                ( )  2.3.10 EMERGENCIA  ( )
0026#STR0026#ALL#                    2.3.7 INFECTADA                  ( )                        
0027#STR0027#ALL#3- PROCEDIMENTOS DIAGNOSTICOS/TERAPEUTICOS
0028#STR0028#ALL#3.1.ANTIMICROBIANO     ( ) 3.8. DRENOS              ( )  3.15.FUNCAO LOMBAR  ( )
0029#STR0029#ALL#3.2.ASPIRACAO          ( ) 3.9. ENDOSCOPIA          ( )  3.16.FUNCAO PLEURAL ( )
0030#STR0030#ALL#3.3.BIOPSIA            ( ) 3.10.ENTUB. ENDOTRAQUIAL ( )  3.17.RESP.MECANICO  ( )
0031#STR0031#ALL#3.4.CATETER VENOSO     ( ) 3.11.HEMODIALISE         ( )  3.18.TERAPIA VENOSA ( )
0032#STR0032#ALL#3.5.CATETER VESICAL    ( ) 3.12.NEBULIZACAO         ( )  3.19.TRAQUEOSTOMIA  ( )
0033#STR0033#ALL#3.6.CORTICOIDE         ( ) 3.13.NUTR.PARENTERAL     ( )  3.20.TRANSF.SANGUE  ( )
0034#STR0034#ALL#3.7.DIALISE PERITONIAL ( ) 3.14.PARACENTESE         ( )  3.21.OUTROS         ( )
0035#STR0035#ALL#Anotar (S)=Sem Infecao, (A)= Infeccao antes procedimento, (D) apos Procedimento 
0036#STR0036#ALL#4-EXAMES MICROBIOLOGICOS: CULTURA( ) CULTURA c/ANTIBIOGRAMA( ) BACTERIOSCOPIA( )
0037#STR0037#ALL#4-EXAMES MICROBIOLOGICOS:
0038#STR0038#ALL#4.1.SECRECOES      ( )     4.3.URINA         ( )       4.5.LIQUOR            ( )
0039#STR0039#ALL#4.2.SANGUE         ( )     4.4.FEZES         ( )       4.6.OUTROS            ( )
0040#STR0040#ALL#                                                       4.7.NAO REALIZOU      ( )
0041#STR0041#ALL#5-DADOS REFERENTES A INFECCAO
0042#STR0042#ALL#LOCALIZACAO TIPOGRAFICA    | NA INTER. | Apos 72Hs | Apos Alta |MICROORG.ISOLADO
0043#STR0043#ALL#5.1. CARDIOVASCULAR    ( ) |    ( )    |    ( )    |    ( )    |
0044#STR0044#ALL#5.2. CIRURGICA         ( ) |    ( )    |    ( )    |    ( )    |
0045#STR0045#ALL#5.3. COLO UMBILICAL    ( ) |    ( )    |    ( )    |    ( )    |
0046#STR0046#ALL#5.4. CUTANEA           ( ) |    ( )    |    ( )    |    ( )    |
0047#STR0047#ALL#5.5. GASTRO INTESTINAL ( ) |    ( )    |    ( )    |    ( )    |
0048#STR0048#ALL#5.6. GENITAL           ( ) |    ( )    |    ( )    |    ( )    |
0049#STR0049#ALL#5.7. OCULAR            ( ) |    ( )    |    ( )    |    ( )    |
0050#STR0050#ALL#5.8. OSTEO-ARTICULAR   ( ) |    ( )    |    ( )    |    ( )    |
0051#STR0051#ALL#5.9. OUVIDO            ( ) |    ( )    |    ( )    |    ( )    |
0052#STR0052#ALL#5.10.PUERPERAL         ( ) |    ( )    |    ( )    |    ( )    |
0053#STR0053#ALL#5.11.SEPTICETEMIA      ( ) |    ( )    |    ( )    |    ( )    |
0054#STR0054#ALL#5.12.TRATO RESP.INF.   ( ) |    ( )    |    ( )    |    ( )    |
0055#STR0055#ALL#5.13.TRATO RESP.SUP.   ( ) |    ( )    |    ( )    |    ( )    |
0056#STR0056#ALL#5.14.URINARIA          ( ) |    ( )    |    ( )    |    ( )    |
0057#STR0057#ALL#5.15.OUTRAS            ( ) |    ( )    |    ( )    |    ( )    |
0058#STR0058#ALL#6- USO DE ANTIBIOTICO
0059#STR0059#ALL#6.1.SIM  (  )     NAO (  )
0060#STR0060#ALL#6.2.ANTIMICROBIANO(S) UTILIZADO(S):___________________________________________
0061#STR0061#ALL#6.3.PROFILATICO CLINICO  (  )             CIRURGICO  (  )
0062#STR0062#ALL#6.4.TERAPEUTICO DE ACORDO COM CULTURA E ANTIBIOGRAMA (  )        EMPIRICO (  )
0063#STR0063#ALL#7- CONDICOES DE SAIDAS
0064#STR0064#ALL#7.1.CURADO  (  )           7.2.MELHORADO  (  )        7.3.INALTERADO  (  )
0065#STR0065#ALL#Data da Alta ____/____/____
0066#STR0066#ALL#8- TIPO DE ALTA
0067#STR0067#ALL#       (  ) INICIATIVA MEDICA    (  ) TRANSFERENCIA      (  ) A PEDIDO          
0068#STR0068#ALL#       (  ) INDISCIPLINA         (  ) ABANDONO           (  ) OBITO             
0069#STR0069#ALL#                                                         (  ) OBITO POR INFECCAO
0070#STR0070#ALL#9- MEDICO ASSISTENTE:___________________  ASS._________________  CRM:___________
0071#STR0071#ALL#   EMFER. ASSISTENTE:___________________  ASS._________________  COREN:_________
0072#STR0072#ALL#10- BACTERIAS
0073#STR0073#ALL#10.1.Acinetobacter SP                10.24.Pseudomonas SP                       
0074#STR0074#ALL#10.2.Alcaligenes SP                     10.25.Pseudomonas Aeruginosa            
0075#STR0075#ALL#10.3.Bordetella SP                      10.26.Salmonella SP                     
0076#STR0076#ALL#10.4.Citrobacter SP                     10.27.Salmonella Enteridis              
0077#STR0077#ALL#10.5.Clostridium SP                     10.28.Salmodella Typi                   
0078#STR0078#ALL#10.6.Corynebacterium Difteriae          10.29.Serratia SP                       
0079#STR0079#ALL#10.7.Edwardsiella                       10.30.Shigella SP                       
0080#STR0080#ALL#10.8.Escherichia Coli                   10.31.Shigella Dysenteriae (Sub Grupo A)
0081#STR0081#ALL#10.9.E. Coli. Enteroinvasora            10.32.Shigella Boydii (Sub Grupo C)     
0082#STR0082#ALL#10.10.E.Coli. EnteroPatog�nico          10.33.Shigella Flexneri (Sub Grupo B)   
0083#STR0083#ALL#10.11.EnteroBacter SP                   10.34.Shigella Sonnei (Sub Grupo D)     
0084#STR0084#ALL#10.12.Haemophilus                    10.35.Staphylococcus Auraus                
0085#STR0085#ALL#10.13.Klebsiella                     10.36.Staphylococcus Epidemidis            
0086#STR0086#ALL#10.14.Lactobacillus SP                  10.37.Staphylococcus SaproPhyticus      
0087#STR0087#ALL#10.15.Listeria Monocytogenes            10.38.Staphylococcus SP                 
0088#STR0088#ALL#10.16.Myco Bacterium SP              10.39.Streptococcus SP                     
0089#STR0089#ALL#10.17.Neisseria Meningitidis            10.40.Streptococcus - nao Hemol�tico    
0090#STR0090#ALL#10.18.Neisseria Gonoraheae              10.41.Streptococcus Virindas            
0091#STR0091#ALL#10.19.Proteus SP                        10.42.Streptococcus Beta Hemolitico (A) 
0092#STR0092#ALL#10.20.Proteus Morganii                  10.43.Streptococcus Beta Hemolitico     
0093#STR0093#ALL#10.21.Proteus Rettgeri               10.44.Streptococcus Fecalis                
0094#STR0094#ALL#10.22.Proteus Vulgaris                  10.45.Streptococcus Pneumoniea          
0095#STR0095#ALL#10.23.Providencia SP                    10.46.Outros                            
0096#STR0096#ALL#11- VIRUS
0097#STR0097#ALL#11.1.Virus A da Hepatite (  ) 11.3.Virus nao A nao B da Hepatite 11.5.Outros ( )
0098#STR0098#ALL#11.2.Virus B da Hepatite (  ) 11.4.Virus HTLV 3                                 
0099#STR0099#ALL#12- FUNGOS
0100#STR0100#ALL#12.1.Candida Albicans    (  ) 12.3.Criptococcus Neoformans      12.5.Outros (  )
0101#STR0101#ALL#12.2.Candida Outras      (  ) 12.4.Criptococcus SP                              
0102#STR0102#ALL#13- TIPO DE INFECCAO
0103#STR0103#ALL#    (  ) Infeccao Comunitaria      (  ) Nao Houve Infeccao          
0104#STR0104#ALL#    (  ) Infeccao Hospitalar       (  ) Infeccao de Outro Hospital *
0105#STR0105#ALL#* ESPECIFICAR O HOSPITAL E A TOPOGRAFIA DA INFECCAO
0106#STR0106#ALL#PLANO:  
 

HSPAHF04_PT-PT.TRES

 0001#STR0001#ALL#Formul�rio De Comiss�o De Controlo De Infec��o Hospitalar
0005#STR0005#ALL#Folha De Controlo De Infec��o Hospitlar
0006#STR0006#ALL#1- Identifica��o
0007#STR0007#ALL#Nome..: 
0008#STR0008#ALL#Sexo:
0009#STR0009#ALL#Idade: 
0010#STR0010#ALL#Cor: 
0011#STR0011#ALL#Registo: 
0012#STR0012#ALL#Sector: 
0013#STR0013#ALL#Conv�nio: 
0014#STR0014#ALL#Tp atendimento: 
0015#STR0015#ALL#Quarto: 
0016#STR0016#ALL#R.n. peso ao nascer:    (  ) < 1.500g      (  ) 1.501g a 2.500g    (  ) > 2.500g
0017#STR0017#ALL#2- dados da hospitaliza��o      inter.anterior neste hospital   sim(  )  nao(  )
0018#STR0018#ALL#2- Dados Da Hospitaliza��o
0019#STR0019#ALL#2.1.diagn�stico Principal:______________________________________________________
0020#STR0020#ALL#2.2.diagn�stico(s) Secund�rio(s)________________________________________________
0021#STR0021#ALL#2.3.cirurgia:___________________________________________________________________
0022#STR0022#ALL#Porte cirurgia      classifica��o da cirurgia               situa��o            
0023#STR0023#ALL#2.3.1.grande  ( )   2.3.4 limpa                      ( )  2.3.8  electiva     ( )
0024#STR0024#ALL#2.3.2. mediana( )   2.3.5 potencialmente contaminada  ( )  2.3.9  urg�ncia    ( )
0025#STR0025#ALL#2.3.3.pequena ( )   2.3.6 contaminada                ( )  2.3.10 emerg�ncia  ( )
0026#STR0026#ALL#                    2.3.7 infectada                  ( )                        
0027#STR0027#ALL#3- Procedimentos Diagn�sticos/terap�uticos
0028#STR0028#ALL#3.1.antimicrobiano     ( ) 3.8. drenos              ( )  3.15.fun��o lombar  ( )
0029#STR0029#ALL#3.2.aspira��o          ( ) 3.9. endoscopia          ( )  3.16.fun��o pleural ( )
0030#STR0030#ALL#3.3.bi�psia            ( ) 3.10.entub. endotraquial ( )  3.17.resp.mec�nico  ( )
0031#STR0031#ALL#3.4.cat�ter venoso     ( ) 3.11.hemodi�lise         ( )  3.18.terapia venosa ( )
0032#STR0032#ALL#3.5.cat�ter vesical    ( ) 3.12.nebuliza��o         ( )  3.19.traqueostomia  ( )
0033#STR0033#ALL#3.6.corticoide         ( ) 3.13.nutr.parenteral     ( )  3.20.transf.sangue  ( )
0034#STR0034#ALL#3.7.di�lise peritonial ( ) 3.14.paracentese         ( )  3.21.outros         ( )
0035#STR0035#ALL#Anotar (s)=sem infec��o, (a)= infec��o antes procedimento, (d) ap�s procedimento 
0036#STR0036#ALL#4-exames microbiol�gicos: cultura( ) cultura c/antibiograma( ) bacterioscopia( )
0037#STR0037#ALL#4-exames Microbiol�gicos:
0038#STR0038#ALL#4.1.secre��es      ( )     4.3.urina         ( )       4.5.liquor            ( )
0039#STR0039#ALL#4.2.sangue         ( )     4.4.fezes         ( )       4.6.outros            ( )
0040#STR0040#ALL#                                                       4.7.n�o realizou      ( )
0041#STR0041#ALL#5-dados Referentes � Infec��o
0042#STR0042#ALL#Localiza��o tipogr�fica    | na inter. | ap�s 72hs | ap�s alta |microorg.isolado
0043#STR0043#ALL#5.1. cardiovascular    ( ) |    ( )    |    ( )    |    ( )    |
0044#STR0044#ALL#5.2. cir�rgica         ( ) |    ( )    |    ( )    |    ( )    |
0045#STR0045#ALL#5.3. colo umbilical    ( ) |    ( )    |    ( )    |    ( )    |
0046#STR0046#ALL#5.4. cut�nea           ( ) |    ( )    |    ( )    |    ( )    |
0047#STR0047#ALL#5.5. gastro-intestinal ( ) |    ( )    |    ( )    |    ( )    |
0048#STR0048#ALL#5.6. genital           ( ) |    ( )    |    ( )    |    ( )    |
0049#STR0049#ALL#5.7. ocular            ( ) |    ( )    |    ( )    |    ( )    |
0050#STR0050#ALL#5.8. osteo-articular   ( ) |    ( )    |    ( )    |    ( )    |
0051#STR0051#ALL#5.9. ouvido            ( ) |    ( )    |    ( )    |    ( )    |
0052#STR0052#ALL#5.10.puerperal         ( ) |    ( )    |    ( )    |    ( )    |
0053#STR0053#ALL#5.11.septicetemia      ( ) |    ( )    |    ( )    |    ( )    |
0054#STR0054#ALL#5.12.tracto resp.inf.   ( ) |    ( )    |    ( )    |    ( )    |
0055#STR0055#ALL#5.13.tracto resp.sup.   ( ) |    ( )    |    ( )    |    ( )    |
0056#STR0056#ALL#5.14.urin�ria          ( ) |    ( )    |    ( )    |    ( )    |
0057#STR0057#ALL#5.15.outras            ( ) |    ( )    |    ( )    |    ( )    |
0058#STR0058#ALL#6- Uso De Antibi�tico
0059#STR0059#ALL#6.1.sim  (  )     n�o (  )
0060#STR0060#ALL#6.2.antimicrobiano(s) Utilizado(s):___________________________________________
0061#STR0061#ALL#6.3.profil�ctico cl�nico  (  )             cir�rgico  (  )
0062#STR0062#ALL#6.4.terap�utico de acordo com cultura e antibiograma (  )        emp�rico (  )
0063#STR0063#ALL#7- Condi��es De Sa�das
0064#STR0064#ALL#7.1.curado  (  )           7.2.melhorou  (  )        7.3.inalterado  (  )
0065#STR0065#ALL#Data da alta ____/____/____
0066#STR0066#ALL#8- Tipo De Alta
0067#STR0067#ALL#       (  ) iniciativa m�dica    (  ) transfer�ncia      (  ) a pedido          
0068#STR0068#ALL#       (  ) indisciplina         (  ) abandono           (  ) �bito             
0069#STR0069#ALL#                                                         (  ) �bito Por Infec��o
0070#STR0070#ALL#9- M�dico Assistente:___________________  Ass._________________  Nr Reg Ordem M�dicos:___________
0071#STR0071#ALL#   Emfer. Assistente:___________________  Ass._________________  Coren:_________
0072#STR0072#ALL#10- Bact�rias
0073#STR0073#ALL#10.1.acinetobact�r sp                10.24.pseudomonas sp                       
0074#STR0074#ALL#10.2.alcaligenes sp                     10.25.pseudomonas aeruginosa            
0075#STR0075#ALL#10.3.bordetella sp                      10.26.salmonella sp                     
0076#STR0076#ALL#10.4.citrobact�r sp                     10.27.salmonella enteridis              
0077#STR0077#ALL#10.5.clostridium sp                     10.28.salmodella typi                   
0078#STR0078#ALL#10.6.corynebacterium difteriae          10.29.serratia sp                       
0079#STR0079#ALL#10.7.edwardsiella                       10.30.shigella sp                       
0080#STR0080#ALL#10.8.escherichia Coli                   10.31.shigella Dysenteriae (sub-grupo A)
0081#STR0081#ALL#10.9.e. coli. enteroinvasora            10.32.shigella boydii (sub-grupo c)     
0082#STR0082#ALL#10.10.e.coli. enteropatog�nico          10.33.shigella flexneri (sub-grupo b)   
0083#STR0083#ALL#10.11.enterobact�r sp                   10.34.shigella sonnei (sub-grupo d)     
0084#STR0084#ALL#10.12.haemophilus                    10.35.staphylococcus auraus                
0085#STR0085#ALL#10.13.klebsiella                     10.36.staphylococcus epidemidis            
0086#STR0086#ALL#10.14.lactobacillus sp                  10.37.staphylococcus saprophyticus      
0087#STR0087#ALL#10.15.listeria monocytogenes            10.38.staphylococcus sp                 
0088#STR0088#ALL#10.16.myco bacterium sp              10.39.streptococcus sp                     
0089#STR0089#ALL#10.17.neisseria meningitidis            10.40.streptococcus - n�o hemol�tico    
0090#STR0090#ALL#10.18.neisseria gonoraheae              10.41.streptococcus virindas            
0091#STR0091#ALL#10.19.proteus sp                        10.42.streptococcus beta hemol�tico (a) 
0092#STR0092#ALL#10.20.proteus morganii                  10.43.streptococcus beta hemol�tico     
0093#STR0093#ALL#10.21.proteus rettgeri               10.44.streptococcus fecalis                
0094#STR0094#ALL#10.22.proteus vulgaris                  10.45.streptococcus pneumoniea          
0095#STR0095#ALL#10.23.provid�ncia sp                    10.46.outros                            
0096#STR0096#ALL#11- V�rus
0097#STR0097#ALL#11.1.v�rus a da hepatite (  ) 11.3.v�rus n�o a n�o b da hepatite 11.5.outros ( )
0098#STR0098#ALL#11.2.v�rus b da hepatite (  ) 11.4.v�rus htlv 3                                 
0099#STR0099#ALL#12- Fungos
0100#STR0100#ALL#12.1.candida albicans    (  ) 12.3.criptococcus neoformans      12.5.outros (  )
0101#STR0101#ALL#12.2.candida outras      (  ) 12.4.criptococcus sp                              
0102#STR0102#ALL#13- Tipo De Infec��o
0103#STR0103#ALL#    (  ) infec��o comunit�ria      (  ) n�o houve infec��o          
0104#STR0104#ALL#    (  ) infec��o hospitalar       (  ) infec��o de outro hospital *
0105#STR0105#ALL#* Especificar O Hospital E A Topografia Da Infec��o
0106#STR0106#ALL#Plano:  
 

HSPAHF04_RU.TRES

 0001#STR0001#ALL#FORM OF COMMISSION FOR CONTROL OF HOSPITAL INFECTION
0002#STR0002#ALL#C. C. H. I.
0003#STR0003#ALL#���.
0004#STR0004#ALL#���.  
0005#STR0005#ALL#HOSPITAL INFECTION CONTROL REPORT
0006#STR0006#ALL#1-IDENTIFICATION
0007#STR0007#ALL#NAME..: 
0008#STR0008#ALL#SEX: 
0009#STR0009#ALL#AGE:   
0010#STR0010#ALL#COMPL.
0011#STR0011#ALL#REGISTRAT.
0012#STR0012#ALL#SECTOR:
0013#STR0013#ALL#HEALTHCARE
0014#STR0014#ALL#ATTEND. TYPE:   
0015#STR0015#ALL#ROOM:   
0016#STR0016#ALL#N.B. Weight at birth:   (  ) < 1.500g     (  ) 1.501g to 2.500g    (  ) > 2.500g
0017#STR0017#ALL#2- HOSPITALIZATION DATA   Previous Admi. in this Hospital   Yes(  )  No(  )
0018#STR0018#ALL#2- HOSPITALIZATION DETAILS
0019#STR0019#ALL#2.1.PRIMARY DIAGNOSIS:______________________________________________________
0020#STR0020#ALL#2.2.SECONDARY DIAGNOSIS________________________________________________
0021#STR0021#ALL#2.3.SURGERY:___________________________________________________________________
0022#STR0022#ALL#Surgery importance  Classification of surgery               Status              
0023#STR0023#ALL#2.3.1.BIG     ( )   2.3.4 CLEAN                      ( )  2.3.8  ELECTIVE    ( )
0024#STR0024#ALL#2.3.2. AVERAGE( )   2.3.5 POTENTIALLY CONTAMINATED   ( )  2.3.9  URGENCY     ( )
0025#STR0025#ALL#2.3.3.SMALL   ( )   2.3.6 CONTAMINATED               ( )  2.3.10 EMERGENCY   ( )
0026#STR0026#ALL#                    2.3.7 INFECTED                  ( )                        
0027#STR0027#ALL#3- DIAGNOSTIC/THERAPEUTIC PROCEDURES
0028#STR0028#ALL#3.1.ANTIMICROBIAL      ( ) 3.8. DRAIN               ( )  3.15.LUMBAR FUNCTION( )
0029#STR0029#ALL#3.2.BREATHING          ( ) 3.9. ENDOSCOPY           ( )  3.16.PLEURAL FUNCT. ( )
0030#STR0030#ALL#3.3.BIOPSY             ( ) 3.10.ENDOTRACHIAL TUBIN. ( )  3.17.MECHANI RESP.  ( )
0031#STR0031#ALL#3.4.VENOUS CATHETER    ( ) 3.11.HEMODIALYSIS        ( )  3.18.VENOUS THERAPY ( )
0032#STR0032#ALL#3.5.VESICAL CATHETER   ( ) 3.12.NEBULIZATION        ( )  3.19.TRACHEOSTOMY  ( )
0033#STR0033#ALL#3.6.CORTICOID         ( ) 3.13.PARENTERAL NUTR.     ( )  3.20.BLOOD TRANSF.  ( )
0034#STR0034#ALL#3.7.PERITONIAL DIALYSIS( ) 3.14.PARACENTESIS        ( )  3.21.OTHERS         ( )
0035#STR0035#ALL#Note (S)=Uninfected, (A)= Infection before procedure, (D) after procedure 
0036#STR0036#ALL#4-MICROBIOLOGICAL EXAMS: CULTURE( ) CULTURE w/ANTIBIOGRAM( ) BACTERIOSCOPE( )
0037#STR0037#ALL#4-MICROBIOLOGICAL EXAMS: 
0038#STR0038#ALL#4.1.SECRECTIONS    ( )     4.3.URINE         ( )       4.5.LIQUOR            ( )
0039#STR0039#ALL#4.2.BLOOD          ( )     4.4.FECES         ( )       4.6.OTHERS            ( )
0040#STR0040#ALL#                                                       4.7.NOT DONE          ( )
0041#STR0041#ALL#5-DATA RELATING TO INFECTION
0042#STR0042#ALL#TYPOGRAPHIC LOCATION       | ON HOSPITAL. | Aft. 72Hs | After Dis |MICROORG.ISOLATED
0043#STR0043#ALL#5.1. CARDIOVASCULAR    ( ) |    ( )    |    ( )    |    ( )    |
0044#STR0044#ALL#5.2. SURGICAL          ( ) |    ( )    |    ( )    |    ( )    |
0045#STR0045#ALL#5.3. UMBILICAL COLON    ( ) |    ( )    |    ( )    |    ( )    |
0046#STR0046#ALL#5.4. CUTANEOUS         ( ) |    ( )    |    ( )    |    ( )    |
0047#STR0047#ALL#5.5. GASTRO INTESTINAL ( ) |    ( )    |    ( )    |    ( )    |
0048#STR0048#ALL#5.6. GENITAL           ( ) |    ( )    |    ( )    |    ( )    |
0049#STR0049#ALL#5.7. OCULAR            ( ) |    ( )    |    ( )    |    ( )    |
0050#STR0050#ALL#5.8. OSTEO-ARTICULAR   ( ) |    ( )    |    ( )    |    ( )    |
0051#STR0051#ALL#5.9. AUDITORY          ( ) |    ( )    |    ( )    |    ( )    |
0052#STR0052#ALL#5.10.PUERPERAL         ( ) |    ( )    |    ( )    |    ( )    |
0053#STR0053#ALL#5.11.SEPTICEMIA      ( ) |    ( )    |    ( )    |    ( )    |
0054#STR0054#ALL#5.12.INF. RESP.TREAT   ( ) |    ( )    |    ( )    |    ( )    |
0055#STR0055#ALL#5.13.SUP. RESP.TREAT   ( ) |    ( )    |    ( )    |    ( )    |
0056#STR0056#ALL#5.14.URINARY          ( ) |    ( )    |    ( )    |    ( )    |
0057#STR0057#ALL#5.15.OTHERS            ( ) |    ( )    |    ( )    |    ( )    |
0058#STR0058#ALL#6- ADMINISTRATION OF ANTIBIOTIC
0059#STR0059#ALL#6.1.YES  (  )     NO (  )
0060#STR0060#ALL#6.2.ANTIMICROBIAL(S) USED:___________________________________________
0061#STR0061#ALL#6.3.CLINICAL PROPHYLATIC (  )             SURGICAL  (  )
0062#STR0062#ALL#6.4.THERAPEUTIC ACCORDING TO CULTURE AND ANTIBIOGRAM (  )        EMPIRIC  (  )
0063#STR0063#ALL#7- CONDITIONS OF EXIT
0064#STR0064#ALL#7.1.CURED   (  )           7.2.IMPROVED   (  )        7.3.UNCHANGED   (  )
0065#STR0065#ALL#Discharge Dt ____/____/____
0066#STR0066#ALL#8- DISCHARGE TP
0067#STR0067#ALL#       (  ) DOCTOR INITIATIVE    (  ) TRANSFER           (  ) UPON REQUEST      
0068#STR0068#ALL#       (  ) INDISCIPLINE         (  ) ABANDONED          (  ) DEATH             
0069#STR0069#ALL#                                                         (  ) DEATH BY INFECTION
0070#STR0070#ALL#9- ASSISTANT DOCTOR:___________________  SIG._________________  SMB:___________
0071#STR0071#ALL#   ASSISTANT NURSE:___________________  SIG._________________  COREN:_________
0072#STR0072#ALL#10- BACTERIA
0073#STR0073#ALL#10.1.Acinetobacter SP                10.24.Pseudomonas SP                       
0074#STR0074#ALL#10.2.Alcaligenes SP                     10.25.Pseudomonas Aeruginosa            
0075#STR0075#ALL#10.3.Bordetella SP                      10.26.Salmonella SP                     
0076#STR0076#ALL#10.4.Citrobacter SP                     10.27.Salmonella Enteridis              
0077#STR0077#ALL#10.5.Clostridium SP                     10.28.Salmodella Typi                   
0078#STR0078#ALL#10.6.Corynebacterium Difteriae          10.29.Serratia SP                       
0079#STR0079#ALL#10.7.Edwardsiella                       10.30.Shigella SP                       
0080#STR0080#ALL#10.8.Escherichia Coli                   10.31.Shigella Dysenteriae (Sub Grupo A)
0081#STR0081#ALL#10.9.E. Coli. Enteroinvasora            10.32.Shigella Boydii (Sub Grupo C)     
0082#STR0082#ALL#10.10.E.Coli. EnteroPatog�nico          10.33.Shigella Flexneri (Sub Grupo B)   
0083#STR0083#ALL#10.11.EnteroBacter SP                   10.34.Shigella Sonnei (Sub Grupo D)     
0084#STR0084#ALL#10.12.Haemophilus                    10.35.Staphylococcus Auraus                
0085#STR0085#ALL#10.13.Klebsiella                     10.36.Staphylococcus Epidemidis            
0086#STR0086#ALL#10.14.Lactobacillus SP                  10.37.Staphylococcus SaproPhyticus      
0087#STR0087#ALL#10.15.Listeria Monocytogenes            10.38.Staphylococcus SP                 
0088#STR0088#ALL#10.16.Myco Bacterium SP              10.39.Streptococcus SP                     
0089#STR0089#ALL#10.17.Neisseria Meningitidis            10.40.Streptococcus - nao Hemol�tico    
0090#STR0090#ALL#10.18.Neisseria Gonoraheae              10.41.Streptococcus Virindas            
0091#STR0091#ALL#10.19.Proteus SP                        10.42.Streptococcus Beta Hemolitico (A) 
0092#STR0092#ALL#10.20.Proteus Morganii                  10.43.Streptococcus Beta Hemolitico     
0093#STR0093#ALL#10.21.Proteus Rettgeri               10.44.Streptococcus Fecalis                
0094#STR0094#ALL#10.22.Proteus Vulgaris                  10.45.Streptococcus Pneumoniea          
0095#STR0095#ALL#10.23.Providencia SP                    10.46.Outros                            
0096#STR0096#ALL#11- VIRUS
0097#STR0097#ALL#11.1.Hepatitis A virus (  ) 11.3.Hepatitis non A non B Virus 11.5.Others ( )
0098#STR0098#ALL#11.2.Hepatitis B virus (  ) 11.4.Virus HTLV 3                                 
0099#STR0099#ALL#12- FUNGI
0100#STR0100#ALL#12.1.Candida Albicans    (  ) 12.3.Criptococcus Neoformans      12.5.Others (  )
0101#STR0101#ALL#12.2.Candida Others      (  ) 12.4.Cryptococcus SP                              
0102#STR0102#ALL#13- INFECTION TYPE
0103#STR0103#ALL#    (  ) Community infection       (  ) There was no infection      
0104#STR0104#ALL#    (  ) Hospital infection        (  ) Infection from other hospital*
0105#STR0105#ALL#* SPECIFY THE HOSPITAL AND TOPOGRAPHY OF INFECTION
0106#STR0106#ALL#PLAN: