Transcription of Inter-facility Infection Control Transfer Form
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Inter-facility Infection Control Transfer Form 7 KLV IRUP PXVW EH ILOOHG RXW IRU WUDQVIHU WR DFFHSWLQJ IDFLOLW\ ZLWK LQIRUPDWLRQ FRPPXQLFDWHG SULRU WR RU ZLWK WUDQVIHU Please attach copies of latest culture reports with susceptibilities if availableSending Healthcare facility : 3 DWLHQW 5 HVLGHQW /DVW 1 DPH )LUVW 1 DPH 'DWH RI %LUWK 0 HGLFDO 5 HFRUG 1 XPEHU BBB BBBB BBBBBBB 1 DPH $GGUHVV RI 6 HQGLQJ )DFLOLW\ 6 HQGLQJ 8 QLW 6 HQGLQJ )DFLOLW\ SKRQH 6 HQGLQJ )DFLOLW\ &RQWDFWV 1$0( 3+21( ( PDLO &DVH 0 DQDJHU $GPLQ 6: ,QIHFWLRQ 3 UHYHQWLRQ Is the patient currently in isolation?
Inter-facility Infection Control Transfer Form 7KLV IRUP PXVW EH ILOOHG RXW IRU WUDQVIHU WR DFFHSWLQJ IDFLOLW\ ZLWK LQIRUPDWLRQ …
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