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Tools and Templates for Long Term 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 long-term care facilities. These documents can be adopted to the needs of the individual facility for improvement in antibiotic prescribing practices.

If you are unable to download these tools using Internet Explorer, try accessing these tools using Google Chrome.

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

Annual ASP Activity Report for LTCF Prescribers

Annual ASP Activity Report for LTCF Staff

Antibiogram Template 1 (Excel format)

Antibiogram Template 2 (Word format)

Antibiotic Use Summary Report Template

ASP Self-Assessment Instrument for LTCF

ASP Extended Assessment Instrument for LTCF

ASP Strategy Implementation Based on LTCF Resources

Educational Topics for Antimicrobial Stewardship in Long Term Care

 

Nebraska LTC Antibiotic Use Database

ASAP LTC AU Database Commitment Letter

ASAP LTC AU Database Monthly Antibiotic Use Submission Portal

 

Infection and Antibiotic Start Log Collections

Infection and Antibiotic Start Log Template

Infection and Antibiotic Start Log Template Version 2

Infection and Antibiotic Start Log Template Version 2 (demo only)

Institutional Policy Template for LTCF ASP

Leadership Support Statement Template for LTCF ASP

Loeb Minimum Criteria for Initiating Antibiotic Checklist

 

SBAR Tool Collections

SBAR Tool for Antibiotic Time Out
SBAR Tool for Suspected Lower Respiratory Tract Infection (LRTI)
SBAR Tool for Suspected Skin and Soft-Tissue Infection (SSTI) (new)
SBAR Tool for Suspected Urinary Tract Infection (UTI)–refer to the companion documents on how to use and implement SBAR tools
SBAR for suspected UTI with treatment recommendations

 

Provider Feedback Letter Templates

Receiving therapy UTI duration 2024

Receiving therapy, not meeting clinical criteria, catheterized 2024

Receiving therapy, not meeting microbiologic criteria, or non-susceptible organism, catheterized 2024

Receiving therapy, not meeting microbiologic criteria, or non-susceptible organism, uncatheterized 2024

Receiving therapy, not meeting clinical criteria, uncatheterized 2024

Therapy completed, not meeting clinical criteria, catheterized 2024

Therapy completed, not meeting clinical criteria, uncatheterized 2024

Therapy completed, not meeting microbiologic criteria, catheterized 2024

Therapy completed, not meeting microbiologic criteria, uncatheterized 2024

Therapy completed, UTI duration 2024

 

 

 

 

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