The form includes four different types of classification, which cover “no apparent inflammation” through “acute inflammation with pus formation, break in aseptic technique”.
The form also includes descriptions of several different types of contaminating factors which can be assigned to wound, as well as space to identify the physicians and staff members working with the patient and postoperative follow-up steps for addressing the wound.
To download a copy of this form you can adapt for use in your ASC, click here (pdf).
Source: Laser Spine Institute
Read about more valuable infection control and quality tools:
– Patient Safety Tool: Guidelines and Procedures for Surgical Site Infections
– Sample Sterile Processing Department Testing and Load Form and QI Worksheet
