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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.

Adverse Drug Reaction Worksheet (new)

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

Blacklight Tracking Workbook

Infection and antibiotic start log template

Infection and antibiotic start log template, version 2

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 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

Page last reviewed: January 31, 2019