Dialysis Event Form printable pdf download

Form Approved

Dialysis Event

OMB No. 0920-0666

Exp. Date: 12/31/2018

Complete this form as indicated by the Dialysis Event Protocol

Instructions for this form are available at

Page 1 of 4

*required for saving

Facility ID:

Event ID #:

*Patient ID:

Social Security #:

Secondary ID #:

Medicare #:

Patient Name, Last:

First:

Middle:

*Gender: F

Other

*Date of Birth:

Ethnicity (Specify):

Race (Specify):

*Event Type: DE – Dialysis Event

*Date of Event:

*Location:

 Yes

 No

*Was the patient admitted/readmitted to the dialysis facility on this dialysis event date?

 Yes

 No

*Transient Patient

Risk Factors

*Vascular accesses: (check all that apply)

*Access placement date (mm/yyyy):

 Fistula

 Unknown 

_____ /_________

 Yes

 No

Buttonhole?

 Graft

 Unknown

_____ /_________

 Tunneled central line

 Unknown

_____ /_________

 Nontunneled central line

 Unknown

_____ /_________

 Other vascular access device, specify:

 Unknown

_____ /_________

 Yes  No

Is this a catheter-graft hybrid?

Vascular access comment: __________________________________________________________

Patient’s dialyzer is reused?

 Yes

 No

Event Details

*Specify Dialysis Event: (check at least one)

 IV antimicrobial start

 Yes  No

*Was vancomycin the antimicrobial used for this start?

Was this a new outpatient start or a continuation of an inpatient course?

 New antimicrobial start

 Continuation of antimicrobial

 Positive blood culture (*specify organism and antimicrobial susceptibilities on pages 2-3)

*Suspected source of positive blood culture (check one):

 Vascular access

 A source other than the vascular access

 Contamination

 Uncertain

*Where was this positive blood culture collected?

 Dialysis clinic

 Hospital

 Other location

or E.D.

(on the day of or the day following admission)

 Pus, redness, or increased swelling at vascular access site

*Check the access site(s) with pus, redness, or increased swelling:

 Fistula

 Graft

 Tunneled

 Nontunneled

 Other vascular

central

line

central line

access device

*Specify Problem(s): (check one or more)

 Fever ≥37.8°C (100°F) oral

 Chills or rigors

 Drop in blood pressure

 Wound (NOT related to vascular access) with pus or increased redness

 Urinary tract infection

 Cellulitis (skin redness, heat, or pain without open wound)

 Pneumonia or respiratory infection

 Other problem (specify): __________________________________________________________

 None

 Yes

 No

 Unknown

*Specify Outcomes:

Loss of vascular access

 Yes

 No

 Unknown

Hospitalization

 Yes

 No

 Unknown

Death

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is

collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent

of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data

sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not

required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect

of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN:

PRA (0920-0666).

CDC 57.502 (Front) Rev 9, v8.5

Dialysis Event Form

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