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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

Antimicrobial stewardship committee meeting minutes template

ASP self-assessment instrument for LTCF

ASP extended assessment instrument for LTCF

ASP strategy implementation based on LTCF resources

Blacklight Tracking Workbook

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)
Infection and antibiotic start log, Access format (contact ASAP for more information)

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 tool for suspected UTI with treatment recommendations

Page last reviewed: August 2, 2019