HEALTH INSTITUTE

BETTER HEALTH, BETTER TOMORROW

ANTIBIOTIC AUDIT FORM

Name of the Patient: __________________________________IDNO: _______________

Age & Sex-_ _ __/_ ___DOA:-___________________DOD:- _____ _________________

Auditor: Dr………………………………………..Specialty: ________________________

Date of Audit: ___________________ Consultant:_______________________________

Health Problems with Description:-

C/O:

DIAGNOSIS:

DRUGS:-
S.
No. Name of Antibiotic Strength Frequency Reason/Remark

1
2
3
4
5
6
7
8
COMMENTS:

Signature of Investigator