ANTIMICROBIAL USAGE DEVIATION FORM

Patient Name: Age/Sex:

UHID: Unit/Ward:
Name of the Consultant: D.O.A:
Diagnosis:

Antibiotic to be prescribed as per Hospital policy: Antibiotic prescribed:

Drug Name Drug Name
Dose Dose
Frequency Frequency

Route Route

Any Other Deviation:

Justification for Deviation:

Clinical Pharmacist Observation:

Comments by stewardship Chairperson:

Justified: YES /NO

[Reason]:
Escalated to Medical Director: YES/NO

Action Taken by Medical Director:

Signature of Medical Director:

Name of the clinical Pharmacist: Signature of Stewardship Team: