Infection Risk Assessment Template Download as PDF Digitalize this paper form now
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Cut inspection time by 50% Uncover more issues and solve them 4x faster Select from over 4000 expert-proofed templates Infection Risk Assessment Template Infection Risk Assessment General Date of Assessment Yes No Risks Respiratory Tract Risks Suspected/confirmed Tuberculosis (TB) AAFB in sputum? Yes No Compliant or non-compliant with drug treatment? Yes No Productive cough with weight loss in last 6 months, with or without fever and night sweats? Yes No Family or other TB contacts? Yes No Previous history of TB and/or incomplete treatment with risk of drug resistance? Yes No Skin Risks Evidence of weeping vesicles e.g. Chicken Pox or Shingles? Yes No Skin Shedding e.g. eczema/psoriasis? Yes No Suspected/confirmed scabies/lice? Yes No An itchy rash or skin lesions? Yes No Elimination Risks Diarrhoea and/or vomiting currently or in the past 12-72 hours? Yes No History of antibiotics in the past 8 weeks? Yes No Recent admission to hospital? Yes No Suspected or confirmed Clostridium difficile? Yes No Urinary Tract Risks Suspected or confirmed urinary tract infection (UTI)? Yes No Recurrent UTI with risks for multi-resistant organisms egESBL’s? Yes No History of antibiotics in the past 8 weeks? Yes No Urinary catheter currently in situ or inserted in the past 6 weeks? Yes No Wound Infection Risks Suspected/confirmed wound infections including MRSA from exudate from Yes No Other wounds that are slow to heal Yes No Blood-Borne Virus (BBV) Risks Suspected/confirmed BBV e.g. Hep B, Hep C, or HIV? Yes No History of IV Drug use? Yes No Behavior which increases infection risks Resistance to assistance with personal hygiene Yes No Physical Disability Yes No Confusion e.g. Alzheimer’s, Dementia etc. Yes No Other Infection Risks Fever of unknown origin, increased confusion/disorientation? Yes No Symptoms with or without any of the above risk factors Yes No Transfer from another hospital or care home within the last 6 weeks Yes No Previous infections Yes No On Completion of the Assessment Does the client need to be isolated from other residents? Yes No N/A Are appropriate referrals made and is treatment commenced promptly? Yes No N/A Infection Control Nurse Contacted By Yes No N/A
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.