SSI Risk Index
A - PATIENT DEMOGRAPHICS AND BASELINE
Smoker:
Patient weight (in pounds): pounds
Patient height (in inches): inches
B - PAST MEDICAL HISTORY
Peripheral vascular disease:
Metastatic Cancer:
Steroid in last month for at least 10 days:
SIRS/Sepsis in last 2 days:
C - SURGICAL INFORMATION
Location, urgency: Out-Patient
  In-Patient, non-emergent
  In-Patient, emergent
Wound Type: Clean
  Clean / Contaminated
  Contaminated / Dirty / Infected
ASA Physical Status Classification:
General Anaesthesia:
Additional procedure by same surgical team:
Total Operation time in hours: hours
CPT Code: