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Data Collection Form Retrospective

This 3 sentence summary provides the key details from the data collection form for a retrospective study on vancomycin therapy: The form collects demographic information like gender, birthdate and age for each patient, along with medical details such as height, weight, current issues, infections being treated, and medication history. Dosing information is included for vancomycin as well as monitoring of efficacy outcomes like trough and peak concentrations. Adverse reactions from the vancomycin therapy like changes in temperature, white blood cell count and kidney function are also tracked.

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jamilah Alnahdi
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664 views3 pages

Data Collection Form Retrospective

This 3 sentence summary provides the key details from the data collection form for a retrospective study on vancomycin therapy: The form collects demographic information like gender, birthdate and age for each patient, along with medical details such as height, weight, current issues, infections being treated, and medication history. Dosing information is included for vancomycin as well as monitoring of efficacy outcomes like trough and peak concentrations. Adverse reactions from the vancomycin therapy like changes in temperature, white blood cell count and kidney function are also tracked.

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

Retrospective 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:
Peak concentration: (mcg/ml)
Total daily dose (TDD):
Sample time (after dose)
Dose per kg (DKg):
Sample time( before dose)
frequency (Tau):
Q4hr(0) Q6hr(1) Q8hr(3) Q12hr(4) Time between level : hr
Q24hr(5)
Infusion time (ti): min Drop in temperature 38 c
Yes (0) / No (1)
Current medical issue: Time when start vancomycin(if yes):

Type of infection being diagnosed: Decrease in WBC count below 25% from the baseline
Empirical Yes (0) / No(1)
Time when start vancomycin(if yes):
Documented
- Site of infection :
Past medical history:

- 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))
Current medication: Antimicrobial medication:

Sensitive/resist
Medication name Dose Frequency Drug name Use or not (check for
ance
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

Crcl

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

Culture:

Name of researcher:

Site:

Time:

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