Point

Prevalence Surveys (PPS) – Data Collection Tool

Patient ID


Name of antimicrobial


Route Choose from:
Parenteral
Oral
Rectal
Inhalation

Unit dose


Number of doses per 24 hours


Indication Choose from:
Community associated infection
Hospital associated infection
Medical prophylaxis
Surgical Prophylaxis

Diagnosis Record the site of infection being treated


Complies with (local) guidance Choose from:
Yes
No
Not assessable

Is the reason for antimicrobial Choose from:
documented? Yes
No

Is a stop or review date Choose from:
documented? Yes
No