Lumiform
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Infection Risk Assessment Template

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Infection Risk Assessment
General
Name of Patient
Date of Birth
Assessed by
Designation
Date of Assessment
Risks
Respiratory Tract Risks
Suspected/confirmed Tuberculosis (TB) AAFB in sputum?
Compliant or non-compliant with drug treatment?
Productive cough with weight loss in last 6 months, with or without fever and night sweats?
Family or other TB contacts?
Previous history of TB and/or incomplete treatment with risk of drug resistance?
Skin Risks
Evidence of weeping vesicles e.g. Chicken Pox or Shingles?
Skin Shedding e.g. eczema/psoriasis?
Suspected/confirmed scabies/lice?
An itchy rash or skin lesions?
MRSA Colonisation
Elimination Risks
Diarrhoea and/or vomiting currently or in the past 12-72 hours?
History of antibiotics in the past 8 weeks?
Recent admission to hospital?
Suspected or confirmed Clostridium difficile?
Urinary Tract Risks
Suspected or confirmed urinary tract infection (UTI)?
Recurrent UTI with risks for multi-resistant organisms egESBL’s?
History of antibiotics in the past 8 weeks?
Urinary catheter currently in situ or inserted in the past 6 weeks?
Wound Infection Risks
Suspected/confirmed wound infections including MRSA from exudate from
Lacerations
Boils
Carbuncles
Venous ulcers
Pressure Sores
Other wounds that are slow to heal
Blood-Borne Virus (BBV) Risks
Suspected/confirmed BBV e.g. Hep B, Hep C, or HIV?
History of IV Drug use?
Behavior which increases infection risks
Not washing hands
Resistance to assistance with personal hygiene
Physical Disability
Confusion e.g. Alzheimer’s, Dementia etc.
Other Infection Risks
Fever of unknown origin, increased confusion/disorientation?
Symptoms with or without any of the above risk factors
Transfer from another hospital or care home within the last 6 weeks
Previous infections
On Completion of the Assessment
What immediate precautions and action will need to be taken?
Does the client need to be isolated from other residents?
If unable to isolate client state why and how they would be managed? E.g. if confused, or refuses to follow advice
Are appropriate referrals made and is treatment commenced promptly?
Infection Control Nurse Contacted By
Date
Referral made to other professionals
(State which)
Date
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.