Information
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Client / Site. Surgery/oncology NTSS Emergency Medicine Critical care Women's and Childrn CTV Musculoskeletal and rehab
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Conducted on
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Prepared by
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Number of charts surveyed
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Number of patients on antimicrobials
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Bleep number
Patient 1
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Patient initials
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Prophylaxis or treatment
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Route
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Antacid
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Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 2
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Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 3
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Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 4
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 5
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 6
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 7
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 8
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 9
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 10
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 11
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 12
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 13
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 14
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 15
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 16
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 17
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 18
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 19
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 20
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 21
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 22
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 23
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 24
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
Patient 25
-
Patient initials
-
Prophylaxis or treatment
-
Route
-
Antacid
-
Drug name
-
If enteral route and administered for longer than 5 days
-
if injected route and administered for longer than 48 hours
-
Does the prescription follow guidelines?
- Yes, Trust guidelines
- Yes, Trus has no guide but follows other guide
- No, no guidelines available
- No, on Micro advice/sensitivities
- Indication not clear (explain below with hospital no)
- No, another reason: wrong drug, dose, route or duration
-
Explanatory notes if required (+ patient hospital number)
