Neonatal Antibiotic Use Assessment Form
Assess neonatal antibiotic use, indication, monitoring, and outcome for a newborn patient.
Neonatal Information
Gestational Age at Birth
*
Please Select
<28 weeks
28–31 weeks
32–36 weeks
37–41 weeks
42+ weeks
Other
Birth Weight (grams)
*
Current Postnatal Age (hours)
*
Current Care Setting
*
NICU
Special Care Nursery
Postpartum Room
Well-Baby Nursery
Pediatric Ward
Other
Antibiotic Exposure and Indication
Were antibiotics started?
*
Yes
No
Antibiotic name(s)
*
Start date and time or age at initiation
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Primary indication for use
*
Please Select
Suspected sepsis
Confirmed infection
Prophylaxis
Maternal risk factors
Other
Assessment and Monitoring
Assessment and Monitoring Items
*
Rows
Reviewed
Not Reviewed
Not Applicable
Cultures obtained
1
2
3
Laboratory markers reviewed
4
5
6
Clinical signs observed
7
8
9
Dose appropriate
10
11
12
Duration appropriate
13
14
15
Antibiotic Decision Outcome
*
Continued
Changed
Discontinued
Submit Assessment
Should be Empty: