Community Pharmacy Antibiotic Checklist data collection tool

 

This form is for you to input the data collected on the TARGET Antibiotic Checklist for community pharmacies as part of the Pharmacy Quality Scheme 2021-22.  

Each page of this form will correspond with each of the 4 pages of the Antibiotic Checklist for individual patient entries. Please double check each answer before proceeding to ensure your form is as accurate as possible. If submitting more than one form, please direct back to the original link after you have submitted your first one.

By completing this form, you understand and agree that PHE/UKHSA may use and share information you provide in relation to this claim internally and with Department of Health and Social Care (DHSC), NHS England and NHS Improvement (NHSEI), and NHS Counter Fraud Authority (NHSCFA) for the purposes of the prevention, detection, loss measurement, investigation and prosecution of fraud or any other unlawful activity affecting the NHS and for the purposes of contract management, provider assurance and service development. The data may be used to make decisions about antimicrobial stewardship to help prevent the development of current and future antimicrobial resistance.

If you have any questions on this form please contact ESPAUR@phe.gov.uk

Q1
Q2
Q3
Q4
Q5

Antibiotic Checklist page 1 - 2: For Patients

Q6
Q7Complete the following information about the patient:
 Yes No Don't know/missing 
 Were the antibiotics for the patient?   
 Was the patient taking any other medicines?   
 Had the patient taken the same antibiotics in the last 3 months?   
 Was the patient allergic to any antibiotics?   
Q8Which of the following common infections did the patient have?
Chest Throat Ear Urine Tooth Skin Don't know/missing Other 
         
  
Q9Did the patient have any of these risk factors?
Problem with kidney function Problem with liver function Breast feeding Pregnant Over 65 None 
       
Q10
Q11
Q12This question requires 2 answers per row. For each of the following statements, tick how the patient answered (if they understood the statement or not) and if the pharmacy team provided information to the patient on this topic.
 Patient ticked yes they understood Patient ticked no they did not understand Missing data for patient Pharmacy team provided advice  Pharmacy team did not provide advice Missing data for pharmacy team 
 I know what to do if I miss a dose of my antibiotics      
 I know whether my antibiotics should be taken with or without food      
 I know why I must take my antibiotics as advised by my doctor, nurse of pharmacist      
 I know about side effects that I might get from my antibiotics      
 I know whether I need to avoid alcohol whilst I am taking my antibiotics      
 I know why I must never share my antibiotics or keep for later use      
 I know how long my symptoms are likely to last      
 I know when I should seek further help with my infection      
 I know why I must return any unused antibiotics to the pharmacy      
Q13If the patient provided contact details, please indicate how they want to be contacted (If they give both, please provide their email address only)
  
 
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