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INFECTION RISK ASSESSMENT INFECTION RISK ASSESSMENT INFECTION RISK ASSESSMENT Attach this sticker to the transfer documentation in ALL cases. Attach this sticker to the transfer documentation in ALL cases. Attach this sticker to the transfer documentation in ALL cases. If you answer yes to any of the questions, contact the admitting area in advance to allow for appropriate isolation to be arranged. If you answer yes to any of the questions, contact the admitting area in advance to allow for appropriate isolation to be arranged. If you answer yes to any of the questions, contact the admitting area in advance to allow for appropriate isolation to be arranged. Does the patient have a previous history of MRSA or another multi-resistant organism? NO Does the patient have a previous history of MRSA or another multi-resistant organism? NO Does the patient have a previous history of MRSA or another multi-resistant organism? YES NO NO Is this patient known or suspected to have pulmonary TB for which they have received less than two weeks treatment/ considered infectious by the TB nurse? NO Is this patient known or suspected to have pulmonary TB for which they have received less than two weeks treatment/ considered infectious by the TB nurse? YES NO NO Following assessment against the viral gastroenteritis algorithm, could the patient have infectious gastroenteritis (viral or other cause)? NO Following assessment against the viral gastroenteritis algorithm, could the patient have infectious gastroenteritis (viral or other cause)? YES NO NO Does the patient have any of the following infections? (circle applicable infections) Chickenpox, slapped cheek, rubella or another infection NO Does the patient have any of the following infections? (circle applicable infections) Chickenpox, slapped cheek, rubella or another infection YES NO Is this patient known or suspected to have pulmonary TB for which they have received less than two weeks treatment/ considered infectious by the TB nurse? Following assessment against the viral gastroenteritis algorithm, could the patient have infectious gastroenteritis (viral or other cause)? YES YES YES Does the patient have any of the following infections? (circle applicable infections) Chickenpox, slapped cheek, rubella or another infection YES YES YES YES YES This form has been completed with information available at the time of the assessment. This form has been completed with information available at the time of the assessment. This form has been completed with information available at the time of the assessment. NAME: .............................................................................. NAME: .............................................................................. NAME: .............................................................................. DATE:......................................... DATE:......................................... DATE:......................................... INFECTION RISK ASSESSMENT INFECTION RISK ASSESSMENT INFECTION RISK ASSESSMENT Attach this sticker to the transfer documentation in ALL cases. Attach this sticker to the transfer documentation in ALL cases. Attach this sticker to the transfer documentation in ALL cases. If you answer yes to any of the questions, contact the admitting area in advance to allow for appropriate isolation to be arranged. If you answer yes to any of the questions, contact the admitting area in advance to allow for appropriate isolation to be arranged. If you answer yes to any of the questions, contact the admitting area in advance to allow for appropriate isolation to be arranged. Does the patient have a previous history of MRSA or another multi-resistant organism? NO Does the patient have a previous history of MRSA or another multi-resistant organism? NO Does the patient have a previous history of MRSA or another multi-resistant organism? YES NO NO Is this patient known or suspected to have pulmonary TB for which they have received less than two weeks treatment/ considered infectious by the TB nurse? NO Is this patient known or suspected to have pulmonary TB for which they have received less than two weeks treatment/ considered infectious by the TB nurse? YES NO NO Following assessment against the viral gastroenteritis algorithm, could the patient have infectious gastroenteritis (viral or other cause)? NO Following assessment against the viral gastroenteritis algorithm, could the patient have infectious gastroenteritis (viral or other cause)? YES NO NO Does the patient have any of the following infections? (circle applicable infections) Chickenpox, slapped cheek, rubella or another infection NO Does the patient have any of the following infections? (circle applicable infections) Chickenpox, slapped cheek, rubella or another infection YES NO Is this patient known or suspected to have pulmonary TB for which they have received less than two weeks treatment/ considered infectious by the TB nurse? Following assessment against the viral gastroenteritis algorithm, could the patient have infectious gastroenteritis (viral or other cause)? YES YES YES Does the patient have any of the following infections? (circle applicable infections) Chickenpox, slapped cheek, rubella or another infection YES YES YES YES YES This form has been completed with information available at the time of the assessment. This form has been completed with information available at the time of the assessment. This form has been completed with information available at the time of the assessment. NAME: .............................................................................. NAME: .............................................................................. NAME: .............................................................................. DATE:......................................... DATE:......................................... DATE:.........................................
