Antibiotic Prescribing Audit Form
Antibiotic Prescribing Audit Form
Audit Reference or Patient Initials
*
Date of Prescription
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Prescriber Name
*
Clinical Indication for Antibiotic
*
Antibiotic Prescribed
*
Dose, Frequency, and Duration
*
Allergy Status Documented?
*
Yes
No
Not Known
Prescribing in Line with Guidelines?
*
Yes
No
Not Applicable
Review or Stop Date Documented?
*
Yes
No
Audit Comments or Notes
Submit Audit
Should be Empty: