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Antimicrobial Form

This antimicrobial use audit form documents a patient's antibiotic use both during and prior to admission to Garg Hospital. It records the patient's name, date, filing information, diagnosis, antibiotics used and their dates, routes and doses. It also notes the patient's indications for IV therapy based on vital signs and lab results. Any previous antibiotic use or allergies are listed. The form is signed by both a microbiologist and clinician.

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Dhananjay Saini
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2K views

Antimicrobial Form

This antimicrobial use audit form documents a patient's antibiotic use both during and prior to admission to Garg Hospital. It records the patient's name, date, filing information, diagnosis, antibiotics used and their dates, routes and doses. It also notes the patient's indications for IV therapy based on vital signs and lab results. Any previous antibiotic use or allergies are listed. The form is signed by both a microbiologist and clinician.

Uploaded by

Dhananjay Saini
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Antimicrobial Use Audit Form

1. Name of patient : Date:


2. Filed by: Specialty:
3. Name & Designation: Diagnosis:
4. Antibiotics used in hospital
Name of antibiotic Date Started Date Stopped Total Days Route Dose

5. Previous Antibiotics Used (Before admission to Garg Hospital)


Name of antibiotic Date Started Date Stopped Total Days Route Dose

6. Indication of current IV Therapy


Temperature: Systolic BP:
≥38° or ≤36° ≤90mmHg
Heart rate: Diastolic BP:
≥90bpm ≤ 60mmHg
Respiratory rate: Urea:
≥20/mm ≥7mmol/L
WBC Count. PO2 ≤8kPa
≤4 or ≥ 12*108/L
CRP
Evidence of infection in other investigation
(soecify)_____________________________________________________________
7. Use of IV route: Complete the information based on the patient’s condition in the preceding 24 Hours
Oral route compromised Yes No Unknown
Eg ↓swallow, ↓absorption, vomiting, unconscious, nil by mouth
Deteriorating clinical condition Yes No Unknown
Patient immunosuppressed? Yes No Unknown
If Yes, please tick the appropriate reason: Malignancy HIV Steroids Other
Immunosuppressive
Any other Yes No Unknown
8. Antibiotic Allergy Recorded
1.
2.
3.
9. Antibiotic Indication

Micro Biologist Sign. Clinician Sign

GH/F136/2016
GH/F136/2016

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