"Infection Prevention and Control Risk Assessment/ Transfer Form"

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Infection 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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Infection 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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Is the Resident at risk
Yes
No
If yes suggested risks reduction (
Comments further/
from the following
to be completed in care plan by
assessment
named carer)
Follow the essential steps for urinary
catheterisation.
Urinary Catheter
Strict hand hygiene
Insitu
Wear clean gloves and aprons when
emptying or accessing system
Empty urine into clean urinal or
directly down toilet
Maintain a closed system, attach night
drainage bag to leg bag tap.
Undertake assessment for the need
for catheterisation. Ensure this is
recorded in care record.
Suspected or
Follow essential steps programme
Take wound swab if signs of infection
confirmed wound
(pus, heat, temperature, pain)
infection
Refer to Tissue Viability
Chronic wounds
Nurse/GP/District Nurse
(pressure sores,
venous ulcers, burns
etc
Blood Borne Viruses
Follow Standard Infection Prevention
and Control Precautions i.e. gloves
(known or suspected)
and aprons when in contact with blood
Hep B, C HIV
and body fluids
Treat any blood spills with a solution of
chlorine i.e. Milton or bleach or use
spill kit.
Skin risks
Follow Infection Prevention and
,
Control policy. Follow Standard
Evidence of weeping
Infection Prevention and Control
vesicles Shingles or
Precautions
Chicken pox
Discuss with GP
Suspected or
confirmed scabies or
lice, itchy skin rash or
skin lesions
Follow Infection Prevention and
Respiratory Risks
Control policy. Follow Standard
Known or suspected
Infection Prevention and Control
influenza
Precautions
Discuss with GP
On chemotherapy or
Discuss with GP
high doses of
steroids
Does the resident require isolation from others?
Y
N
Has the Community Infection Prevention and Control Nurse been informed Y N
Date:
Name of person who made contact: …………………………
Telephone no. 0121 6121627
Referral to other professionals (state Which) ………………………….. Date………………
If risks identified ensure risk reduction strategy is incorporated in Residents Care Plan
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