Postoperative Antibiotic Audit Form
Review postoperative antibiotic prescribing and administration for a surgical case, including timing, duration, protocol adherence, outcomes, and audit findings.
Patient and Procedure Context
Patient Identifier / Chart Reference
*
Age or Age Range
*
Sex / Gender
Female
Male
Intersex
Non-binary
Prefer not to say
Other
Surgery / Procedure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure Type
*
Surgical Specialty / Ward
*
Please Select
General Surgery
Orthopedics
Gynecology
Urology
Neurosurgery
Cardiothoracic
ENT
Vascular
Plastic Surgery
Other
Urgency of Surgery
*
Elective
Urgent
Emergency
Wound Class / Contamination Level
Please Select
Clean
Clean-contaminated
Contaminated
Dirty/Infected
Unknown
Not applicable
Antibiotic Prophylaxis Details
Was postoperative antibiotic prophylaxis prescribed?
*
Yes
No
Antibiotic name
*
Route of administration
*
Please Select
Oral
Intravenous
Intramuscular
Topical
Other
Dose
*
Frequency
*
Please Select
Once daily
Twice daily
Three times daily
Four times daily
Every 6 hours
Every 8 hours
Every 12 hours
As directed
Other
Start time relative to surgery end
*
Stop date and time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Intended duration (days)
Given within the required postoperative window?
Yes
No
Not applicable
Protocol not specified
Audit Compliance and Clinical Review
Did the antibiotic regimen match the local protocol or guideline?
*
Yes
No
Partially
Not sure
Reason for any deviation from protocol/guideline
Factors that influenced continuation of antibiotics
Positive culture results
Clinical signs of infection
Raised inflammatory markers
Ongoing surgical site concerns
Patient instability
Microbiology advice
No clear indication documented
Other
Were any adverse drug reactions or intolerance documented?
None documented
Mild reaction
Moderate reaction
Severe reaction
Suspected allergy
Other
Were antibiotics discontinued appropriately?
*
Yes
No
Not applicable
Unable to determine
Reviewer assessment of overall appropriateness
*
Appropriate
Mostly appropriate
Requires improvement
Inappropriate
Audit notes and recommendations
Reviewer Information
Reviewer name or role
*
Department
*
Audit date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Follow-up action status
*
No action needed
Clinician notified
Protocol correction required
Follow-up planned
Submit Audit
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