Antimicrobial Therapy Assessment
Evaluate and document antimicrobial therapy for clinical appropriateness and stewardship.
Patient Initials
*
Patient Age
*
Hospital/Unit
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Infection Site
*
Please Select
Respiratory tract
Urinary tract
Bloodstream
Skin/Soft tissue
Intra-abdominal
Other
Antimicrobial Agent(s) Prescribed
*
Indication for Antimicrobial Therapy
*
Please Select
Empiric therapy
Definitive therapy
Prophylaxis
Other
Assessment of Therapy Appropriateness
*
Rows
Appropriate
Inappropriate
Not Assessable
Choice of agent
1
2
3
Dose
4
5
6
Route of administration
7
8
9
Duration
10
11
12
Adverse Effects Observed
None
Gastrointestinal
Allergic reaction
Renal toxicity
Hepatic toxicity
Other
Antimicrobial Stewardship Recommendation
*
Continue current therapy
De-escalate therapy
Escalate therapy
Discontinue therapy
Other
Reviewer Name and Role
*
Additional Comments or Recommendations
Submit Assessment
Should be Empty: