FILE IN SECTION 3 sean ae Write patient details or affix ae Identification label wan wma Hospital Number: conta oe Address: DATE OF ADMIN waa wort DATE WRITTEN ‘DATE REWRITTEN, Date of Birth: | CHART, of __NHS Number: HAS THE VTE RISK ASSESSMENT FORM BEEN COMPLETED? M@ PLEASE ALLERGY STATUS should be confirmed and documented prior to medication being prescribed. Please indicate if there are no known allergies i.e. NKA Allergy or Sensitivity to: ‘Type of Reaction (eg. rash) Signature: Date: Der kinnucrcadincn mkukeleniatn Pe nie, Mice Auer | ONCE-ONLY and PRE-MEDICATION ae oe ee ee ee ee OXYGEN (Gee CORP/GUID/312 for guidance) Continual review as per POTTS Chart Tar oxTewoNT “TEK OR INSERT TIES REQUIRED TRAE TTT RT A A TTT OT woo PRCT seme "Hee saranTon nor OCA] ome RS TNT I TN EATS EP aR ORE IOFONE Device Code: Venturi Mask (VI4%); Simple Face Mask (SFM); Humidified (H%); Non-rebreathing Mask (NRB); Nasal Cannulae (NC); Huimidified via Trace Mask (T¥M%)Antimicrobials should be prescribed in accordance with the Antimicrobial Formulary ANTIBIOTICS ONLY -—_ SETHE AEOTRED | oa oa loos woute | suarone | svorowe PRcREETS SUTURE (ASO PRT ANE CEARE) | GU | BEEP - weTON sasmianes aceon a woe [onTeNs ERMAN T puataace om toa om room | svarome [sor one Faces seniu so marian cca) | Gichanbe | A woo Sasimaes | ecxo aves — _ im ™ I enna WAN mauenacy | en SO Tas oH ae rou | searoae | sweome PRESCRIBER'S SIGNATURE (ALSO PRINT NAME CLEARLY) Gwe Number | eee | of be = INDCATION ~] sensmrivmes micro approve, + ms {i mm ‘ADOTTONAL RFORVATON inane 1 1 b3— ig | Dose ‘ROUTE ‘START DATE | ‘STOP DATE | [rscmaersscnarne so awruame cen) | twcnome | ome | | TocaTOH Tsessmares” | wcnoazrorr | — = ia wn “ADDITIONAL INFORMATION PHARMACY | i fo ig ot ot ‘Dose ive ‘ROUTE ‘START OATE | STOP DATE Rae TR HP _ 1 OTN SasmaTes: wacko aD: }—t — im ‘m "ADDITIONAL INFORMATION ‘PHARMACY, | Pia eum mee iia rlrnieetiiicncd orallas soon as possible: All Antibiotics/are valid for 5 days only:FILE IN SECTION 3 Write patient details or affix =e Identification label wand “HOSPITAL | Hospital Number: cost Name: Address: Tate OF we a cae oaTeRENATCN Date of Birth: CHART. . of = NHS Number: | OE A EL ST SE a el a ele aed 87S L¢ REGULAR est ATE ONT aon SRT Ts REQUIRED “DALTEPARIN sic IST SE ERATE AS PRAT EER -DBTORACNFORNATON “* ANTI-EMBOLISM STOCKINGS CT TTR NSO PROT RAE ERR r TOUR] SCARE TTR ST PT HOE ERRTT FOBITORAORUATON PRES ERATE SPAT WACO — |B AODTONAL RFORHATION ET STATA PNT WANE RNY — |S SOTA HART Ta TOOT] SATE] TOPO IAT AS HT ECE |S THOTT FORT iamREGULAR Weak DATO TW OF WSS EOURES TESTA SOP OTT 4 ESET HOT RS MRT ATT} FET pee TTA TRON ARE ERE TOATAETST HENTAI) —|AET pewe oa ETAT NORTON aT RET TENT TST PEATE) |W es TOA TERIOR ae { a UR ONE BE RES STE VEE PRTC | soa TT TORT rar ME ome] Tor | aT DTT FONT FERRET TSD RTI |B ee TOTO aR? Tor OE] SORE] FORT AT SRA RT NTT ERG) |“ ce TOTTI aAS REQUIRED care | vat | cut [rou] "ca | se |v | xe me | oe BO TONE =a RATT FOS) ERT TET PART RACER) — EF Cos fa — rT a ara ORT TIT 7 a a OTSA RETF ra co TO RR RATATAT SS SATA ATE CEA] ERT Ta au ane — RTT SCRE ATR SG PRT HAR CTS ar a Tam — TTF SSAA SORT TERT werANTICOAGULANT TREATMENT (see CORP/GUID/310) EXISTING / NEW PATIENT Anticoagulant book issued || Counselling provided __By. Date. Surname... First Name... Hosp. No. Anticoagulant Duration of Treatment .. Diagnosislindication Date Started neocon 1» Desired Range of INK Dowage | Prescribers Signature | glee, ae Borage | Prescribers Sonature | gia Date | WR | mgdoy | txonrntname ceaiy) | Meer | WR | mg ésy (lo print rane clei | O°? NON-ADMINISTRATION OF MEDICINES (see CORP/PROC/307) WHEN THE PATIENT DOES NOT RECEIVE THE PRESCRIGED DOSE, THE NURSE MUST ENTER A NON-ADMINISTRATION CODE. INFORM DOCTOR If DRUG OMITTED. 1. Patient refused 4. Nil by mouth 2. Patient away from ward 5. Medicine unavailable (attempt to obtain failed) 3. Patient unable to receive medicines/or no access 6. SelFadministered medicinesior no access 7. Other reason ~ see notes INSTRUCTIONS FOR USE Sign and print your name clearly against each prescription (© Use APPROVED DRUG NAME and print each entry LEGIBLY IN CAPITAL LETTERS in © Do not use abbreviation of drug names. Always write units and micrograms in full, (© NEVER alter existing instructions ~ write a new entry, ‘When drugs are discontinued draw a diagonal ine through the drug name and administration sections. Date and sign cancellation ‘© All antibiotic prescriptions MUST have an indication and stopireview date. © Additional advice available in Prescribing Medicines CORP/PROC30}. lack indelible ink. Pharmacists - note any significant Insert ¥ to indicate checks or assessments completed Sig/Date intervention/pharmaceutical care problem Drug history checked/medicines| Details of admission medication: fecorelag lease note problemsiomissions) Sig/DaterTime ee Allergy status checked 7 SigiDate Drug rewrite checked SigiDate PODs checked 7 SigDete TTO completed SigiDate Compliance aid in use NO/YES “prove the an Records Cone TORE