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Infection Risk Assessment Template

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Infection Risk Assessment Template

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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