| ID # |
NH Name |
NH Unit |
Extraction Date |
Gender |
Age |
Date of NH Admission |
NH Admission Dz |
Antibiotic #1 |
Antibiotic #2 |
Antibiotic #3 |
Prescription Date |
Indication |
First Dose given (Date & Time) |
Febrile within 24 hours of first round of prescription(s)? Yes/No |
Culture(s) Yes/No |
If Culture is Obtained date(s)/time(s) |
Source(s) |
Organism(s) |
Date(s) of organism ID |
Date of sensitivity results |
Cultured Organism sensitive to antibiotic |
Reason for changing antibiotic |
Febrile within 24 hours of second round of prescription(s)? Yes/No |
Antibiotic #1 |
Antibiotic #2 |
Antibiotic #3 |
Prescription Date |
Indication |
First Dose given (Date & Time) |
Second Culture(s) Yes/No |
If Second Culture is Obtained date(s)/time(s) |
Source(s) of second culture |
Organism(s) of second culture |
Date(s) of second organism ID |
Date of second sensitivity results |
Second Cultured Organism sensitive to antibiotic |
Reason for second change of antibiotic |
Febrile within 24 hours of third round of prescription(s)? Yes/No |
Antibiotic #1 |
Antibiotic #2 |
Antibiotic #3 |
PrescriptionDate |
Indication |
First Dose given (Date & Time) |
Third Culture(s) Yes/No |
If Third Culture is Obtained date(s)/time(s) |
Source(s) of third culture |
Organism(s) of third culture |
Date(s) third of organism ID |
Date of third sensitivity results |
Third Cultured Organism sensitive to antibiotic |
Transferred to ED during course of treatment? (Yes/No) |
If Yes, Transferred during which round of Treatment? |
Date of transfer to ED |