REKAMAN+PEMBERIAN+ANTIBIOTIK

REKAMAN PEMBERIAN ANTIBIOTIK (RPA)Rumah Sakit .....................................................

Dep./SMF ...................................................Nama: ............. .............................................................. Jenis Kelamin : L / P No DMK : ..............................................

Umur : ............ Thn ............ bln Berat : ........ kg Ruang : ...................................... Lembar ke : ..............................................

Nama Antibiotik & Dosis Regimen Lama Penggunaan: tanggal

Pemberian Jam Pr Jam Pr Jam Pr Jam Pr Jam Pr Jam Pr Jam Pr Jam Pr Jam Pr Jam Pr Jam Pr Jam Pr

Tx Profilaxis Jam :

Tx Empiris Jam :

Tx Definitf Jam :

Informasi : T.T. Dr Jam :

T.T Apt Jam :



Tx Profilaxis Jam :

Tx Empiris Jam :

Tx Definitf Jam :

Informasi T.T. Dr Jam :

T.T Apt Jam :



Tx Profilaxis Jam :

Tx Empiris Jam :

Tx Definitf Jam :


T.T Apt Jam :



Tx Profilaxis Jam :

Tx Empiris Jam :

Tx Definitf Jam :


T.T Apt Jam :

Sufficient data

AD Justified

Alternative more effective

Alternative less toxic

Alternative less expensive

Alternative narrower spectrum

Duration too long

Duration too short

Correct dose

Correct Interval

Figure 1. Flow chart for quality of use evaluation of antimicrobial drug prescriptions ( Alur Gyssens)

Start

No Stop

Correctroute

If not in categories

II -IV

I

VI

Base Line Study Reviewed case no: Reviewer : I /II / III No of Medical Record

RESUME OF ANTIMICROBIAL USAGE INFORMATION AND CATEGORIZATION

Note:ADE: Antimicrobial Drug Empiric Therapy; ADET : Antimicrobial Drug Extende Empiric Therapy; ADD : Antimicrobial Drug Documented Therapy; ADP: Antimicrobial Drug Prophylaxis; ADU : Antimicrobial Drug Unknown Therapy; AA : Alternative Agent

Type of Therapy

Generic Unit Dose (mg)

Freq (X)

Route Stop : d/m/y

Duration (days)

Total Doses

Category / GroupI II III IV V VI

A B C A B A B C DADE

Aa

ADE

Aa

ADE

Aa

Aa

AD

Aa

Aa

Antimicrobial Recistance Control Program (ARCP)INFORMATION FOR REVIEWER TO ASSESS

THE QUALITY OF ANTIBIOTIC USAGE

ANTIBIOTIC USAGENO Name of Antibiotic Daily Dose

(Mg)Route

Oral, ivType of therapy (T,P,U)

Indication (UTI,etc)

Day of antibiotic usage (start from day on admission)1 2 3 4 5 6 7 8 9 10 11 12

Note: T; Treatment; P: Prophylaxis; U: UnknownUTI : Urinary tract Infection

Day of antibiotic usage (start from day on admission)NO 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

Position of the doctor who is prescribing:1. resident2. specialist (supervisor or consultant)

condition patient at discharge :1. cured2. death

REKAMAN+PEMBERIAN+ANTIBIOTIK

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