Documentation/Infection Control
Module guide · Clinical
Infection Control
Hospital-wide infection surveillance: log and confirm an infection case, escalate a cluster into a tracked outbreak, trace and monitor everyone exposed, and audit hand hygiene against the WHO Five Moments.
What this module is for
Restricted to infection-prevention staff and the clinical/leadership roles who need visibility: physicians, nurses, nurse managers, admins, directors, quality, compliance, and safety officers.
Who uses it
Infection Control practitioners run surveillance, investigate outbreaks, and manage contact tracing. Physicians and nurses confirm or rule out cases and treat them. Quality, Compliance and Safety Officer roles monitor rates and reporting status.
Where to find it
Open Infection Control from the sidebar. Five screens: a dashboard, Infection Records, Outbreak Alerts, Contact Tracing, and Hand Hygiene.
- 1
Log a case
A suspected or probable infection record is created for a patient, with site, acquisition type, and isolation details.
- 2
Confirm or rule out
A clinician confirms the case (per NHSN criteria) or rules it out, each with a documented reason.
- 3
Escalate if needed
A cluster of related cases becomes a tracked Outbreak Alert, which can activate the Incident Command System and trigger contact tracing.
- 4
Trace and monitor
Everyone exposed is logged as a contact, monitored for symptoms, quarantined if needed, and followed until resolved.
A few terms you'll see throughout
Dashboard
An executive view over a chosen date range, with an alert banner for any active outbreak.
Stat tiles
| Field | What it means |
|---|---|
| Active Infections, Confirmed, Suspected | Case counts for the selected date range. |
| Total HAIs, Total MDROs | Total MDROs is highlighted red when above zero. |
| CLABSI Rate, CAUTI Rate, VAP Rate, HAI / 1,000 Patient-Days | Device-associated and overall infection rate metrics. |
| Hand Hygiene Compliance | Percentage of compliant observations this range. |
| Pending NHSN Reports, Pending Public Health Reports | Highlighted red when above zero, both are unfinished regulatory reporting. |
An active-outbreak banner lists up to 5 active outbreaks by pathogen, severity, and case count when any exist. Charts show a 12-month HAI trend, infections by site, and MDROs by resistance profile.
Infection records
Search, log, and manage individual infection cases, from initial suspicion through cultures, antibiotic treatment, and resolution.
New Infection Record form
| Field | What it means |
|---|---|
| Patient, Pathogen* | |
| Pathogen / Infection ICD-10 | Optional coding fields. |
| Infection Site* | 20 sites, e.g. CLABSI, CAUTI, VAP, the 3 SSI (Surgical Site Infection) subtypes, C. difficile, Skin/Soft Tissue. Defaults Other. |
| Acquisition Type* | Community, Hospital-Acquired, Healthcare-Associated, Long-Term Care Facility, Surgical Site, or Device-Associated. Defaults Community. |
| Identified Date | Defaults today. |
| Isolation Type, Isolation Room | Contact, Droplet, Airborne, their Reverse/protective variants, or Combined. |
| Resistance Profile | MRSA, VRE, ESBL, CRE, CRAB, CRPA, CRKP, PDR, XDR, MDR, or None. |
| Hospital-acquired (HAI), MDRO, Device-associated, Notifiable disease | Checkboxes; Device-associated reveals a Device Type field. |
A record's detail page has four tabs: Overview, Culture Results, Antibiotics, and History. Cultures record specimen type/site, result, organism, and interpretation. Antibiotic treatments record drug, dosage, route, and sensitivity, and can be marked as having undergone an antimicrobial stewardship review.
Workflow actions (status-gated)
| Field | What it means |
|---|---|
| Confirm | While Suspected/Probable; requires a reason, defaults to "Confirmed per NHSN criteria". |
| Rule Out | While Suspected/Probable; requires a reason. |
| Resolve | While Confirmed; sets today as the resolved date. |
| Report to NHSN / Report to Public Health | Independent one-click flags, available any time they haven't been reported yet. |
Suspected / Probable — under investigation
Confirmed — verified case
Ruled Out — investigation cleared it
Resolved — case closed out
Chronic / Deceased — long-term or terminal outcome
Outbreak alerts
Track a cluster of related infections as a single outbreak: escalate its severity, coordinate response, and link individual cases.
New Outbreak Alert form
| Field | What it means |
|---|---|
| Pathogen* | |
| Severity | Watch, Warning, or Critical. Defaults Watch. |
| Start Date, IPC Lead | Infection Prevention & Control lead, staff picker. |
| Affected Areas | Free-text tags added one at a time, e.g. "ICU-3". |
| Control Measures* | |
| Epidemiological Summary, Lab Findings |
Escalating and responding
Escalate raises severity with a required reason. Activate ICS turns on the Incident Command System for major-outbreak coordination. Affected Areas and Exposed Staff can be added at any time.
Linking and closing
Link Case attaches an existing infection record to the outbreak. Report Public Health records a case number. Close Outbreak requires closure notes and is available until status is already Closed.
Watch — lowest severity, being monitored
Warning — elevated concern
Critical — highest severity
Contact tracing
Log everyone exposed to a pathogen — patient, staff, or visitor — and monitor them through symptoms, quarantine, and resolution.
New Contact Tracing Record form
| Field | What it means |
|---|---|
| Contact Type* | Patient, Staff, or Visitor. Defaults Patient; reveals the matching name field. |
| Exposure Date* | Defaults today. |
| Exposure Duration (min), Exposure Location | |
| Exposure Route | Direct Contact, Droplet, Airborne, or Fomite. |
| Link to Infection Record / Outbreak | Optional typeahead pickers tying the contact back to its source. |
| Monitoring Start / End, Assigned Investigator |
The list can be filtered to Active Monitoring, or grouped by outbreak, infection record, patient, staff member, or status.
Ongoing monitoring actions on a contact's detail page
| Field | What it means |
|---|---|
| Symptoms | Records "No Symptoms" or "Symptoms Developed", with optional notes. |
| Order Quarantine | Sets a quarantine start and end date. |
| Add Prophylaxis | Free-text record of post-exposure medication, dose, and duration. |
| Mark Secondary Case | Links this contact to a newly created infection record once they've developed the infection themselves. |
Pending / In Progress — monitoring underway
Completed — monitoring period finished
Lost to Follow-Up / Refused — monitoring couldn't continue
Hand hygiene audits
Record and report on hand-hygiene compliance observations against the WHO Five Moments framework.
Record Hand Hygiene Audit form
| Field | What it means |
|---|---|
| Unit* | |
| Room Number, Audited At | Audited At defaults to now. |
| WHO Moment* | Before Patient Contact, Before Aseptic Procedure, After Body Fluid Exposure Risk, After Patient Contact, After Patient Surroundings Contact. |
| Staff Category* | Nurse, Physician, Allied Health, Support Staff, or Visitor. |
| Observed Staff | Optional, the specific person being observed. |
| Method Used* | Alcohol Hand Rub or Soap and Water. |
| Compliant, Feedback given | Checkboxes; Compliant defaults checked. |
| Duration (seconds), Observer, Notes |
The dashboard shows overall compliance against a target rate (red-highlighted if the target isn't met), total and compliant observation counts, and charts of compliance by unit and by WHO moment. A table lists every non-compliant observation for follow-up. CSV and Excel exports cover the selected date range, with an optional unit filter for Excel.
Good practices
Document the reason for confirm and rule-out
Escalate outbreaks with a documented reason
Report to NHSN and Public Health promptly