Form #1 Form #1 Loeb Criteria Communication and Order Form

Attachment B: Loeb Criteria Communication and Order Form

Form Approved
OMB No. XXXX-XXX
Exp. Date XX/XX/XXXX

Communication and Order Form

Please use the communication and order form to document all infections.

P

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

lease use Section II to document whether a resident has a skin or soft tissue infection, a urinary tract infection, a suspected lower respiratory tract infection, or a fever of unknown origin.

Please fill out as much information as possible, indicating whether the Loeb criteria were met.

Communication and Order Form (v.8)

Clinician:	Facility:
Fax:	Facility Nurse:
Phone:	Phone:
Resident/Rm#:	Date & Time faxed/reported:

I. Vital Signs: Temp.: ________ BP: _____________ Resp. Rate: ________ Heart Rate: ________ O₂ Sat:_________

II. Infections and Fevers- Loeb Criteria for Antibiotic Use (CHECK ALL THAT APPLY)

 Skin or Soft Tissue Infection, check all that apply Site:____________________________________  New or increasing purulent discharge at site  OR AT LEAST TWO of the following:  Fever over 100F or increase of 2.4F above baseline temp.;  Redness;  Tenderness;  Warmth;  New/increased swelling  Loeb criteria met	 Fever of Unknown Origin, check all that apply  Fever over 100F or increase in 2.4F above baseline patient needs to have AT LEAST ONE of the following:  Delirium  Rigors (shaking chills)  Loeb criteria met
	 Suspected Lower Respiratory Infection (choose 1 of 4)  For patients with a fever: (1)  If fever is 102F or greater Pt. must also have AT LEAST ONE of the following:  Resp. rate > 25 breaths/min.  Productive cough (2)  If fever is between 100 - 102F Pt. MUST have a  Cough AND AT LEAST ONE of the following:  Pulse > 100  Delirium  Rigors  Resp. rate >25 breaths/min  For patients without a fever: (3)  If Pt. does not have COPD, Pt. must have  New or increased cough with purulent sputum production AND AT LEAST ONE of the following:  Resp. rate > 25 breaths/min.  Delirium (4)  If Pt. has COPD Pt. must have  New or increased cough with purulent sputum production  Loeb criteria met
 Suspected Urinary Tract Infection (choose 1 of 2) (1)  For Pts. with a chronic indwelling catheter, check at least 1:  Fever over 100F or increase of 2.4F above baseline  New costovertebral angle tenderness (flank pain)  Rigors (shaking chills)  Delirium (sudden onset of confusion) (2)  For Pts. without a chronic indwelling catheter, check all that apply:  Acute dysuria OR  Fever over 100F or increase in 2.4F above baseline temp. AND AT LEAST ONE new or worsening:  Urgency;  Frequency;  Suprapubic pain ;  Gross hematuria ;  Costovertebral angle tenderness; or  Urinary incontinence  Loeb criteria met

III. Additional information ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________

FAMILY/POA NOTIFIED: Date & Time reported: ____________________ Name: _______________________________________

^{Nurse Signature Date/Time}

IV. Clinician’s Orders

Treatment # 1:_________________________ Dosage: ______________________________ Frequency:____________________________ Other: _______________________________	Treatment #2: ________________________ Dosage: __________________________ Frequency:_________________________ Other:_____________________________	 Lab Tests: ________________ ___________________________  X-ray ordered  No changes at this time
Comments/Other Instructions:
Clinician Signature Date/Time  Telephone order received

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