• There must be documentation of an infection/suspected infection, other than pneumonia, within 24 hours after arrival in order to select “Yes” for this data element.
• Only consider infections/suspected infections that are being/will be treated by an ANTIBIOTIC listed in Appendix C, Table 2.1, that are administered via routes PO, IM or IV. There does not need to be documentation that ties the antibiotic to the infection/suspected infection, as one antibiotic may cover multiple infections.
• Documentation of signs or symptoms (e.g., 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.
• This data element will accept both “suspected” infections and “diagnosed” infections. Examples: Upon arrival, there is physician documentation the patient has cellulites, select “Yes”. In the ED, after arrival, there is physician assistant documentation that she suspects the patient has a UTI, select “Yes.”

PHYSICIAN/ADVANCED PRACTICE NURSE/PHYSICIAN ASSISTANT DOCUMENTATION ONLY

• Consult notes
• ED records
• History and Physical
• Physician's notes
• Admit notes
• Progress notes