Form D Attachment D: Team Antibiotic Review Form

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment D: Team Antibiotic Review Form

TEAM ANTIBIOTIC REVIEW FORM

Questions 1-6 should be answered for all patients on antibiotics that you evaluate. Teams should review at least 10 cases per month in real time, not retrospectively.

Question 1: Day of antibiotic therapy: (choose one)

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 >7 Question 2: Antibiotic regimen and indication:

Antibiotic Indication Antibiotic Indication Antibiotic Indication Antibiotic Indication

Moment ONE Question 3 Does the patient have a suspected or confirmed infection that requires antibiotics?	Yes	No
Moment TWO Question 4 Were appropriate cultures ordered before antibiotics were started? Question 5 Were specific reactions for reported antibiotic allergies documented? Question 6 Were empiric antibiotics compliant with local guidelines?	Yes Yes Yes	No No No	N/A N/A N/A

Public reporting burden for this collection of information is estimated to average 15 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.

Questions 7-14 should be answered for patients on antibiotics > 24 hours in addition to questions 1-6 above.