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Data Collection Form Prospective

This 3 sentence summary provides the key information from the data collection form for a prospective study on vancomycin therapy: The form collects demographic information about patients receiving vancomycin like age, weight, medical issues and medications. It also tracks dosing details for vancomycin like dose, frequency and infusion time. Finally, the form monitors efficacy outcomes from vancomycin therapy like temperature, white blood cell count, serum creatinine and bacteriological clearance.

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jamilah Alnahdi
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120 views

Data Collection Form Prospective

This 3 sentence summary provides the key information from the data collection form for a prospective study on vancomycin therapy: The form collects demographic information about patients receiving vancomycin like age, weight, medical issues and medications. It also tracks dosing details for vancomycin like dose, frequency and infusion time. Finally, the form monitors efficacy outcomes from vancomycin therapy like temperature, white blood cell count, serum creatinine and bacteriological clearance.

Uploaded by

jamilah Alnahdi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Data collection form

prospective study

Date: Gender:
Date of admission: Male (0)
Patient ID:
Patient code: Birth date:
The number of days in the hospital prior to vancomycin Age:
therapy: Age category:
Gestational age (in weeks): -30 days) (0)
Preterm Full-term - 2years) (1)
Height (cm): -12 years) (2)
Weight (kg): - 16 years) (3)
BSA:
Efficacy outcomes:
Dosing data: Trough concentration (mcg/ml)
Initial dose of vancomycin:
Sample time (after dose)
Total daily dose (TDD):
Drop in temperature 38 c
Dose per kg (DKg): Yes (0) / No (1)
Time when start vancomycin(if yes):
frequency (Tau):
Q4hr(0) Q6hr(1) Q8hr(3) Q12hr(4) Decrease in WBC count below 25% from the baseline
Q24hr(5) Yes (0) / No(1)
Infusion time (ti): min Time when start vancomycin(if yes):

Current medical issue:


Type of infection being diagnosed:
Past medical history:
Empirical
Documented
- Site of infection :

- Type of bacteria:
MIC:
Bacteriological clearance : ( Yes(0)/No(1))
Time:

Diagnosis :

Temperature at start:
WBC at start:
Cardiopulmonary bypass procedure
(Yes(0) /no(1))
Bp at start: HR at start:
RR at start:
Current medication: Antimicrobial medication:

Sensitive/resista
Medication name Dose Frequency Drug name Use or not (check
nce
for Yes)
(S /R)

Steroid If yes: Duration:


(corticosteroids) Dose:

TAZOcin

Gentamycin

AMIKacin

Amphotericin

ACYCLOVIR
Panadol

paracetamol

Ciprofloxacin

Clindamycin

Trimethoprim/Sulfa

cefotaxime
Amoxicillin/Clavulanate

Ampicillin

Azithromycin

Mupirocin(bactroban
cream)
Linezolid

Tetracycline

Rifampin

CUFROXIME

ibuprofen

Name of Antibiotics:
Other Antibiotics
Date baseline

Srcr

WBC

Temp

BUN

Platelets

RR

HR

BP

Crcl

At least two or three sequent rising in serum creatinine by 0.5 mg/dl, or at least (25%-50%) rise from the baseline
Yes (0)
(1)

Calture:

Name of researcher:

Site:
Time:

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