Page 66 - DESIGN-A

Remarks

Prescriber

If Empiric Reason for cont. beyond 72 hours

If Definitive/ Empiric to Definitive Source Culture

Treatment Duration (Days) Stop Date

Compliance to guideline Start Date

Empiric/ Definitive/ Empiric to Definitive

Indication of Antibiotic
EXAMPLE OF ANTIBIOTIC AUDIT FORM

MRN

Dose & Patient Frequency

ANTIBIOTIC: Ward Month

64 Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities | Second Edition 2022