Page 1 of sample form
Page 2 of sample form
Surgical Site Infection Surveillance General Surgery Form
DRAFT PERI OPERATIVE cont. Q 17 Category of surgical procedure
Tick only one procedure below (the main procedure) and fill out the OPCS code in box provided
Serial number
OPCS-4 Code:
Endocrine System and Breast Pituitary and pineal glands Thyroid and parathyroid glands Other endocrine glands Breast Upper Digestive Tract Duodenum Jejunum Ileum Other
Hepatobiliary, Pancreas and Spleen Liver Gall bladder Spleen Bile duct Pancreas Other
Lower Digestive Tract Appendix Colon Anus and perianal region Soft Tissue Hernia Repair Other Rectum
Stomach pylorus and general upper GI tract endoscopy Oesophagus including hiatus hernia Vascular Aorta Carotid cerebral and subclavian arteries Abdominal branches POST OPERATIVE Q 18 Has patient developed a surgical site infection? Q 19 Type of surgical site infection Superficial incisional Deep incisional Organ/space Q 21 Outcome of the patient Discharge
Iliac and femoral arteries Other arteries Veins and other blood vessels
Yes
No
Q 20 Date infection was diagnosed D D / M M / Y Y Y Y
D D / M M / Q 22 Date of Outcome
Y Y Y Y
Transfer Death Not recorded Q 23 Date surveillance completed