Ventilator Associated Pneumonia Worksheet – VAMC West Palm BeachCindy Lang, BSN, RN, CIC – Senior Infection Control Specialist

Name________________________________Last 4 SSN_________________________Diagnosis_______________________________________________________________________________________________________________________________________Date of Admission________________________________________________________

Precautions/Reason_______________________________________________________________________________________________________________________________Code Status_____________________________________________________________Respiratory Status_______________________________________________________Ventilator – Intubation/Trach Date________________________________________________________________________________________________________________Days on ventilator________________________________________________________HOB___________________________________________________________________________________________________________________________________________________________________________________________________________________Stress Ulcer Prophylaxis___________________________________________________

DVT Prophylaxis

Daily Sedation Vacation/Assessment Readiness to Wean/Daily Spont BreathingTrial

Antibiotics______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Micro Data______________________________________________________________

Imaging/CXR/Bronch_____________________________________________________

Temp/WBC_____________________________________________________________Ventilator Associated Pneumonia – YES / Date NO (Circle) -______

C. Lang, BSN, RN, CIC 1/07 VAMC WPB