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Run: Antibiotic Stewardship Tracking Log

Track each antibiotic start in a nursing home with a monthly log for indication, criteria review, duration, and pharmacist or medical director follow-up.

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Log Details

Log Month (required)

Select any date within the month being reported; the month will be used for monthly tracking.

Facility or Unit (required)

Enter the nursing home facility name or unit where the antibiotic was started.

Submitted By (required)

Name and role of the staff member completing this log entry.

Antibiotic Start Date (required)

Date the antibiotic was started.

Antibiotic Start Details

Antibiotic Name (required)

Enter the medication name. Avoid including unnecessary patient identifiers.

Indication for Start (required)

Briefly document the clinical indication or suspected infection being treated.

Prescriber Type (required)

Is this a new start or a restart? (required)

Criteria Review

Criteria Used for Review (required)

Select all criteria frameworks used to evaluate the antibiotic start.

Were criteria met? (required)

Criteria Details

If criteria were not met or only partially met, summarize the gap or rationale.

Suspected Infection Site

Duration and Review

Planned Duration (Days) (required)

Enter the planned number of treatment days.

Actual Duration Completed (Days)

Enter the completed duration if treatment has ended.

Pharmacist Review Completed? (required)

Medical Director Review Completed? (required)

Review Notes

Document recommendations, follow-up actions, or reasons for exceptions.

Follow-Up and Attestation

Is follow-up required? (required)

Follow-Up Owner

Name or role responsible for follow-up, if needed.

Follow-Up Due Date

Attestation (required)

By submitting, you confirm the log entry is accurate and will be retained in the stewardship audit trail.

Yes No N/A

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Email (required)

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