Antimicrobial Stewardship Monitoring/Program Form
Name of the Patient:
Age of the Patient:
Height of the Patient:
Weight of the Patient:
Allergies:
Diagnosis:
Pneumonia
UTI
Meningitis
Line infection
Cellulitis
Intra-abdominal Infection
Other
Lab results:
Creatinine Clearance:
Blood and culture sensitivity:
Antimicrobial(s)
Drug #1
Name:
Dose:
Route:
Frequency:
Duration:
Antimicrobial(s)
Drug #2
Name:
Dose:
Route:
Frequency:
Duration:
The date when the patient started to take the antibiotics:
Drug #1:
Drug #2:
The date when the patient will stop taking the antibiotics:
Drug #1:
Drug #2:
Antimicrobial(s) to discontinue:
The reason/s why there should be an extension of taking antibiotics for more than seven days:
Drug #1:
Drug #2:
Order Written
Date:
Time:
Pharmacy:
Pharmacist:
Contact #:
West Visayas State University Medical Center 2020
Submit
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