The document outlines active surveillance forms used at the Pakistan Kidney and Liver Institute and Research Center for tracking patient data related to invasive lines, infections, and other medical parameters. It includes fields for patient demographics, clinical signs, diagnostic tests, and interventions. The forms are intended for detailed monitoring of patient conditions and outcomes during hospitalization.

1. PAKISTAN KIDNEY AND LIVER
INSTITUTE AND RESEARCH CENTER
ACTIVE SURVEILLANCE FORM
1
IPC F0040, Ver:02, ED:26-01-2023
Patient Name: ________________
MR#: _______________________
INVASIVE LINES
Date & Dept
Central line (Site, Insertion &
Removal)
IV Catheter (Site, Insertion &
Removal)
Arterial Catheter (Site, Insertion &
Removal)
ETT (Insertion & Removal)
Foley Catheter
Insertion & Removal
Bed Sore Stage (CA/HAI)
Antimicrobials (Dose & Route)
CLABSI/CRBSI Sign & Symptoms
TLC Or CRP
Temperature (max/Min) last 24 hrs
Observer Name: Gender
(M/F)
Bed/Room # Code status: Date of admission Date of
Discharge
Age: Transferred from: Transferred to Date of transfer
Diagnosis Consultant Name: Any surgery if yes
(specify)
Screen (base line cultures) if any HAI: (Yes/No)
(CLABSI, CAUTI, VAP
Patient status (Alive/Expired)

2. PAKISTAN KIDNEY AND LIVER
INSTITUTE AND RESEARCH CENTER
ACTIVE SURVEILLANCE FORM
2
IPC F0040, Ver:02, ED:26-01-2023
Patient Name: ________________
MR#: _______________________
Date & Dept
Hypotension (Max/Min) last 24 hrs
Blood/Tip CS
(organism + site)
Phlebitis (stage, CA/HA)
Mucositis (Stage, CA/HA)
CAUTI/UTI Sign & Symptoms
Color of Urine (Pyuria) Y/N
Suprapubic, Tenderness/Pain Y/N
Frequency (Y/N)
Urgency (Y/N)
Dysuria (Y/N)
Urine CS (Organism & site)
VAE/VAP Sign & symptoms
PEEP 0-5>
FIO2 %
New Abx changed
Purulent Respiratory secretions
+ve.
Pleural fluid/biopsy +ve
BAL/tracheal CS +ve