Infection Prevention And Control Risk Assessment/ Transfer Form
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3Infection Prevention and Control Risk Assessment/ Transfer Form
(To be completed for all Residents on arrival at the home and incorporated into Residents care
plan or when being transferred to other health facilities)
Name:
Transferred from:
Address:
Transferred too:
Date of Birth:
Date of Transfer:
Date of Admission
Reason for Transfer:
Hospital Number
Transfer Contact:
Name of GP
Tele No.:
Tele No.
Date of Assessment:
MRSA Risk Assessment
Known History of MRSA Y N
Date swab taken: ………………………………
Site of colonisation/infection i.e. Skin/Wound
Urine
Sputum
Nose
Groin
Other
Resident currently on decolonisation treatment ( skin washes and nasal ointment) Y N
Diarrhoea and or Vomiting/C.diff Risk Assessment
Is the client currently having diarrhoea and or vomiting (D&V) where infection has not been
ruled out? Y N
If yes has specimen been obtained Y N
Result……………………………
Has the client been exposed to diarrhoea and or vomiting in the past 72 hours (i.e. other
cases of D&V in the home, hospital or by family member/carer? Y N
Has the client a history of clostridium difficile? Y N
Date of diagnosis………………….
Is client currently symptomatic (i.e. having active diarrhoea)?
Y N
Has a stool specimen been taken Y
N
Date……………. Result……………………
Other relevant information: i.e. Current antibiotics, Contact with infection
Has the client received a seasonal influenza vaccine within the past twelve months? Y N
Date:………………………..
If no please give reason:
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Parent category: Business