Antibiotic Stewardship Checklist Form
Use this form to document and review antibiotic stewardship tasks. Title: Antibiotic Stewardship Checklist Form.
Review Identifier (e.g., initials or non-sensitive code)
Date of Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Antibiotic Name Prescribed
*
Indication for Antibiotic Use
*
Route of Administration
*
Please Select
Oral
Intravenous
Intramuscular
Other
Duration of Therapy (days)
*
Allergy Checked
Yes
Dose Appropriate for Indication
Yes
De-escalation Considered/Reviewed
Yes
Documentation in Patient Record Completed
Yes
Submit Checklist
Should be Empty: