| Patient ID # |
Date & Time of ED Transfer |
NH Name |
Date of NH Admission or Length of NH Stay |
Reason for Transfer to ED |
Was culture sent at ED? |
Date & Time Culture #1 Obtained |
Culture #1 Obtained - source fluid |
Date & Time Culture #2 Obtained |
Culture #2 Obtained - source fluid |
Date & Time Culture #3 Obtained |
Culture #3 Obtained - source fluid |
Date and Time of ED Arrival |
ED Arrival Chief Complaint |
Name(s) of Arrival Antibx #1 |
Number of days on Antibz #1 |
Name(s) of Arrival Antibx #2 |
Number of days on Antibz #2 |
Date and Time of ED Departure |
Name of Departure Antibx #1 |
Departure abx 1 - duration of recommended therapy (days) |
Name of Departure Antibx #2 |
Departure abx 2 - duration of recommended therapy (days) |
Name of Departure Antibx #3 |
Departure abx 3 - duration of recommended therapy (days) |