Antimicrobial Request List

From Date

Approved

Not Approved

Pending

All

Restricted 7th Day

HospNum	Adm #	Patient Name	Request Date & Time	Requested by	Medication	Approving Officer	Approval Date & Time	Received By	Received Date & Time	Select		OrderID
	2B		May 30 2024 2:12 PM	MEDSYS, SLUSHMC	Voriconazole IV	DOCTOR, SLU				Open Form		353173

Patient ID: Reg#

Age:
Sex:
Weight:
Room:

Serum Creatinine:
SGPT
SGOT:
ALP:

ANTIMICROBIAL

DOSE

FREQUENCY

ROUTE

DURATION

INDICATION

TYPE OF INFECTION/DIAGNOSIS

Comorbid Illnesses

Previous Antimicrobials

Allergies

Culture and Sensitivity Request

Culture and Sensitivity Results

PRE-AUTHORIZATION

APPROVAL DETAILS

AMS Officer

Status

Remarks

Date and Time

REQUEST DETAILS

Requesting Physician

Recommendations/Remarks

PHARMACIST-IN-CHARGE

Received By

Remarks

Date and Time Received