OPAT Monitoring Note (Weekly)

OPAT Monitoring Note (Weekly)

Date/Time of Review: [date and time]

Author/Role: [author name, credentials, service]

Encounter Type: [direct contact (phone/video/in-person) / chart review only]; Sources reviewed: [EHR labs, infusion pharmacy MAR, home health RN note, other] (If chart review only, do not document symptom denials or normal findings for Clinical Status or Toxicity Screen.)

Interval Covered: [prior review date] → [current date]

OPAT Summary

• Indication: [diagnosis, anatomic site, device-associated if applicable]
• Microbiology: [organism(s), key susceptibilities; blood culture clearance date if bacteremia]
• Timeline: OPAT start [date], Day #[number], Week #[number], planned stop date [date or endpoint criteria]
• Current Regimen: [drug, dose, route, frequency, infusion method; renal/hepatic adjustments if applicable]
• Vascular Access: [line type, side, placement date] (If placement date unknown, state explicitly and note action taken to obtain.)
• Monitoring Plan: Next labs [date], next drug level [date if applicable], next OPAT review [date]
• Changes This Week: [No changes / brief summary of modifications] (Must match details in Assessment & Plan.)

Interval Review

Clinical Status: [fever, local infection symptoms, pain, functional status, wound/drain changes, ED visits or rehospitalizations, source control updates] (If no patient contact, state explicitly that symptom review was not obtained and list sources reviewed.)

Adherence: [source of data: patient report / pharmacy MAR / home health log]; [doses administered/expected]; [missed or delayed doses with reason and mitigation if applicable]

Line Status: [function (flush/aspirate), site condition with date and source of most recent assessment, complications if any]

Toxicity Screen: [symptoms reviewed relevant to regimen: GI, derm, neuro, renal, drug-specific concerns] (Tailor to current antimicrobial. If chart review only, state that symptom review was not obtained.)

Labs/Levels: [most recent values with draw date, trend, abnormalities highlighted; for drug levels include type (trough/AUC), timing relative to dose, and target range] (If expected labs missing, document what is missing, reason if known, action taken, and interim safety plan.)

New Micro/Imaging: [results since last review] (Omit if none.)

Assessment & Plan

Primary Infection: [improved / stable / worsening] with supporting data; source control status; oral step-down candidacy; duration remaining and endpoint criteria

Antimicrobial Management: [continue / modify] current regimen; [rationale]; dose appropriateness for current renal/hepatic function; [changes made this week with reason and communications completed]

Line Management: [current status, issues requiring intervention, plan for complications if any]

Toxicity/Adverse Events: [toxicities identified, attribution, actions taken] (Omit if none.)

Adherence/Logistics: [issues and mitigation, refill and continuity plan] (Omit if no issues.)

Orders & Follow-up

• Orders Placed: [labs, drug levels, home health orders]
• Communications Completed: [infusion pharmacy, home health, patient/caregiver with names/roles]
• Pending Items: [action items and responsible party] (Omit if none.)
• Escalation Instructions: [when to call OPAT line vs go to ED]
• Next OPAT Review: [specific date]
• Next Labs Due: [specific date and location]
• Next Clinic Appointment: [date/time or scheduling task owner]