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Tools and Templates for Acute Care

Resources developed by Nebraska ASAP are intended for non-commercial educational and quality improvement purposes. Please acknowledge Nebraska ASAP when they are used.

Below is a collection of tools and templates developed for acute care facilities.  These documents can be adopted to the needs of individual facility for improvement in antibiotic prescribing practices.


Adverse Drug Reaction Worksheet (PDF format) (Word format)


Antibiogram Templates for Frequently Isolated Pathogens, with Summary Comments


Antibiotic Use Tracking Template


Antimicrobial Stewardship Intervention Database Template


Antimicrobial Stewardship Recommendation Form Template


Antimicrobial Stewardship Self-Assessment Instrument for Acute Care Hospitals


Automatic IV to PO Antibiotic Conversion Policy Template


Daily Antibiotic Therapy Checklist Template


Institutional Policy Template for Hospital ASP


Leadership Support Statement Template for Hospital ASP


Piperacillin-tazobactam Therapy Checklist Template


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