• If there is documentation of an infection or possible/suspected infection, select “Yes.”
• Documentation of symptoms (example: fever, elevated white blood cells, etc.) should not be considered infections unless documented as an infection or possible/suspected infection. Example: Do not assume infection if a wound/surgical site is described as reddened, swollen and hot, as other conditions can also cause these symptoms.
• The physician/APN/PA documentation of postoperative infection must be written after surgical incision.
• If documentation of an infection occurs more than two days postoperatively (three days for CABG or Other Cardiac Surgery) with the day of surgery being day zero, select “No.”
• Only accept documentation of a postoperative infection in discharge summaries that are dated (dictated or written) within 2 days (3 days for CABG or Other Cardiac Surgery) postoperatively with the day of surgery being day zero. If the discharge summary is dated (dictated or written) outside of that timeframe, it should not be considered documentation of a postoperative infection.

• Anesthesia record
• Consultation notes
• Progress notes
• Discharge summary

Note:
Do NOT use Table 5.09 as a reference for Postoperative Infections. This data element has an inclusion table to use as a guideline that provides the types of infection that are acceptable. Please reference this inclusion table when answering this data element.