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Refer a patient

Intravenous antibiotic referral form


Patient details
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Is an interpreter required?: * required


Is this a first appointment?: * required


Housebound?: * required


Is this a referral for IV antibiotics?: * required



(and ring the relevant team to triage)
Is this patient previously known to community nursing?: * required


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Referrer
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* required
(please state reason for IV therapy)
Acceptance criteria
Patient requires IV/IM/SC medication: * required


Medication with patient: * required


Discharge notification with patient: * required


IV treatment
Cannula in situ: * required


Type of IV line: * required





* required
   
Consumables supplied: * required


Prescription includes water for injection: * required



Treatment
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Frequency of treatment:
If frequency is TDS/QDS these must be discussed with the clinical team before the referral is accepted.




* required
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(time using 24 hr clock)
   
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(end date)(time using 24 hr clock)
   
Is this Bolus or Infusion: * required



Has the patient had their first dose in hospital?: * required


Did they experience any adverse effects?: * required



Infection control status
Is the patient known to have any current infections or history of MRSA?: * required



Has the patient a recent history of vomiting and/or diarrhoea?: * required






* required
* required

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

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