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
Revised McGeer Criteria for Infection Surveillance 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 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
