D Attachment D: Team Antibiotic Review Form

Form Approved
OMB No. 0935-0238
Exp. Date 09/30/2020

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

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

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