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G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 1 of 22
Surname
Title Address
Forenames Date of Birth RT/NHS number
Care Co-ordinator GP
CPMS number
Consultant Allergies
One booklet to be completed for each patient initiated on clozapine treatment
Approved by the Horizon Scanning and Prescribing Guidance sub group 23 November 2012 Review date: 23 November 2015
Integrated Care Pathway (ICP)
for the
Management of clozapine
COMMUNITY INITIATION
Document Reference MM 049
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 2 of 22
Contents
Page
1 Pre-initiation phase of clozapine 3 - Checklist 2
Routine baseline assessment
4
3
Decision processes for initiation of clozapine
5
4
Rationale
5
5 Community initiation pathway 6
5.1 Titration
5.2 Monitoring and observations 6 Community initiation standard dose regime 7 7 Community initiation pathway observation record 8 – 11
Appendix 1
Clozapine initiation observations information 12
Appendix 2
Clozapine home treatment care plan 13 – 17
Appendix 3 Community initiation of clozapine treatment prescription Day 1 – 7
18
Appendix 4 Community initiation of clozapine treatment prescription Day 8 – 14
19
Appendix 5 Community initiation of clozapine treatment prescription Day 15 – 21
20
Appendix 6 Community initiation of clozapine treatment prescription Day 22 – 28
21
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 3 of 22
PRE-INITIATION PHASE 1 Pre-initiation phase of clozapine. A full description for the initiation of clozapine is given in the Summary of Product Characteristics (SPC) for ‘Clozaril®’. All staff involved in this process should familiarise themselves fully with these guidelines.
Pre-initiation checklist
YES
NO
Does the patient have a diagnosis of treatment resistant schizophrenia?
Has the patient been prescribed two previous antipsychotic agents, including a second generation antipsychotic, for a minimum of six weeks each?
Does the patient fulfil the criteria for other indications as per the SPC?
- Severe, untreatable neurological adverse reactions to other antipsychotic agents.
- Psychotic disorders occurring during the course of Parkinson’s Disease, where standard treatment has failed.
- Has there been a full multidisciplinary meeting to discuss initiation as per CPA policy (Consultant Psychiatrist, Care Co-ordinator and other interested/involved parties)?
Has the clinical team given consideration to the identified contra-indications to the use of clozapine?
Contraindications (SPC ‘Clozaril’ – Novartis Pharmaceuticals UK)
Patients unable to undergo regular blood tests.
History of toxic or idiosyncratic granulocytopenia/agranulocytosis (with the exception of granulocytopenia/ agranulocytosis from previous chemotherapy).
History of clozapine-induced agranulocytosis.
Impaired bone marrow function.
Uncontrolled epilepsy.
Alcoholic and other toxic psychoses, drug intoxication, comatose conditions.
Circulatory collapse and/or CNS depression of any cause.
Severe renal or cardiac disorders (e.g. myocarditis).
Active liver disease associated with nausea, anorexia or jaundice; progressive liver disease, hepatic failure.
Paralytic ileus.
Has the General Practitioner been contacted to determine any concurrent physical health concerns/investigations/treatments, and the use of any other prescribed medications as per Procedure for medicines reconciliation on admission of patients to hospital (MM 026)?
Clozapine treatment must not be started concurrently with drugs known to have a
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 4 of 22
substantial potential for causing agranulocytosis; concomitant use of depot antipsychotics is to be discouraged. PLEASE NOTE: If the answers to the questions above contraindicate the initiation of clozapine treatment, please refer to the following points:
• If the answers to the check list above are specifically contraindicated by the Clozaril Patient Monitoring System (CPMS) the patient must not be commenced on clozapine and must be referred back to the Consultant
• If there is a complexity issue or unlicensed use issue then a further multidisciplinary team (MDT) meeting is called, the issues are discussed and a decision made regarding inpatient or community initiation of clozapine.
2 Routine Baseline Assessment
Completed
Full medical and psychiatric history (including previous treatment concordance).
Physical examination: weight, height, pulse, blood pressure (sitting and standing), temperature, and waist circumference
Electrocardiogram
Blood tests
Full blood count
Differential white cell count
LFTs
U & Es
Lipids
TFTs
Random blood glucose
Troponin I or T
CRP
Medicines reconciliation – GP contacted to advise of all medications prescribed and any other physical health concerns/treatments
Substance history including alcohol, smoking, caffeine, illicit substances Details: -
COMPLETE BASELINE OBSERVATIONS using Community Initiation Pathway
Observation Record (Page 8).
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 5 of 22
3 Decision Processes for the initiation of clozapine
YES
NO
Patient agreeable to initiation of treatment?
Carers present?
Carers agreeable to support initial treatment regime?
Diagnosis confirmed?
Physical health acceptable?
Bloods taken and within acceptable ranges?
Consent obtained?
Decision to initiate treatment?
Inpatient initiation
Outpatient initiation
4 Rationale Concurrent processes prior to initiation of clozapine. Check that the following has been completed: -
Completed
Inform pharmacy department/ mental health pharmacist.
Inform CPMS and obtain registration number
Inform clozapine clinic of intention to treat
Inform General Practitioner (GP) (See GP support pack)
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 6 of 22
COMMUNITY INITIATION PATHWAY 5 Community initiation pathway
YES
NO
Patient is aware of the need for daily attendance/ home visit by Home Treatment (HT) Team?
A Clozapine Home Treatment Care Plan has been completed and is in place? (See APPENDIX )
GP has been informed of clozapine start date?
A carer/ relative should stay with the patient overnight and this has been agreed?
Contact numbers have been given? (HT Team, CPMS advice line, GP, Nurse on Block/ Wards)
The patient has a GREEN result from CPMS?
The Community Initiation of Clozapine Treatment Prescription Day 1 – 7 has been completed and dispensed by pharmacy ready for Day 1 [insert day of the week]?
An observation record has been completed and is in place?
5.1 Titration
Dependant on tolerability and results of physical observations, it may be necessary to slow down the titration regime in some cases.
5.2 Monitoring and observations.
• Complete Clozapine Initiation Observations (Appendix 1)
• Complete Community Initiation Pathway Observation Record (Page 8)
It is imperative that observations are undertaken when initiating clozapine in community settings as robustly as in inpatient settings. The team responsible for community initiation will stay with the patient for the 6 hours necessary to complete all observations. A review will be undertaken by the SHO/SHO on call/Advanced Practitioner. If observations are stable and following review, the patient can be at home with family/carer support with advice to contact HT Team/attend A&E/other if necessary and as appropriate. A Home Treatment Care Plan must be completed and in place before the patient returns home. (See Appendix 2). Please also refer to
• Guidelines for the monitoring of physical health for patients taking clozapine (MM 042)
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 7 of 22
6 Community Initiation Dose Regime. Pre-initiation checks complete and baseline assessments fully completed and ready to start on first day of initiation. This should always be Tuesday to take weekends into account for supplies of medication. The Advanced Practitioner/ SHO clerks in patient and takes initial blood samples to ensure a green blood result is obtained from CPMS before initiation begins. Result from CPMS. The dose and monitoring regime outlined below is a guide to treatment as recommended by the manufacturer of Clozaril, Novartis, and is available via the website www.clozaril.co.uk and the Clozaril Patient Monitoring Service (CPMS).
• Monitoring and observation of the patient should be undertaken as outlined in the table from page 8.
• The first Community Initiation of Clozapine Treatment Prescription for Day 1 – 7, must be completed by the prescriber and issued by pharmacy when a green result is obtained and before treatment begins. Subsequent prescriptions to be completed as required (Appendix 3 – 6) or complete the inpatient prescription chart and variable dose section, and request supplies from pharmacy using an outpatient prescription.
• Advanced Practitioner/ SHO to review patient prior to leaving department.
• When observations remain within normal range and the patient is stable on the dose regime, observations may be stopped. A discussion must take place with the Consultant to confirm that the observations and dose are stable. At this point the patient will normally be discharged from the HT into care of the care co-ordinator and Consultant unless an alternative arrangement has previously discussed and agreed by the Advanced Practitioner/SHO.
• The patient should be monitored through the current clozapine clinic pathway and via the GP.
• Blood tests should be taken on Days 1, 8, 15 and 22.
• Medical and pharmacy review twice a week on initiation and weekly thereafter.
Day Morning dose
Evening dose
Day Morning dose
Evening dose
1
Tuesday
12.5mg
NIL
15
Tuesday
100mg
125mg
2
Wednesday
25mg
NIL
16
Wednesday
100mg
150mg
3
Thursday
37.5mg
NIL
17
Thursday
100mg
175mg
4
Friday
50mg
NIL
18
Friday
100mg
200mg
5
Saturday
50mg
NIL
19
Saturday
100mg
200mg
6
Sunday
50mg
NIL
20
Sunday
100mg
200mg
7
Monday
75mg
NIL
21
Monday
100mg
250mg
8
Tuesday
50mg
50mg
22
Tuesday
100mg
250mg
9
Wednesday
50mg
75mg
23
Wednesday
100mg
250mg
10
Thursday
75mg
75mg
24
Thursday
100mg
250mg
11
Friday
75mg
100mg
25
Friday
100mg
300mg
12
Saturday
75mg
100mg
26
Saturday
100mg
300mg
13
Sunday
75mg
100mg
27
Sunday
100mg
300mg
14
Monday
100mg
100mg
28
Monday
100mg
300mg
Result / Date
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 8 of 22
7 Community Initiation Pathway Observation Record
BP
Temperature
Pulse
Observations
Sitting
Standing
Baseline
DAY 1 DATE ……………………. (Tuesday)
Pre AM dose 15 mins post AM dose
Ho
url
y f
or
6
ho
urs
po
st
AM
d
ose
1 hour 2 hours 3 hours 4 hours 5 hours 6 hours
DAY 2 Date …………..(Wednesday)
Pre AM dose 15 mins post AM dose
Ho
url
y f
or
6
ho
urs
po
st
AM
d
ose
1 hour 2 hours 3 hours 4 hours 5 hours 6 hours
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 9 of 22
BP
Temperature
Pulse
Observations
Sitting
Standing
DAY 3 to 7
3
Thur
AM
Pre dose 2 hours post 6 hours post
4 Fri
AM
Pre dose 2 hours post 6 hours post
5
Sat
AM
Pre dose 2 hours post 6 hours post
6
Sun
AM
Pre dose 2 hours post 6 hours post
7
Mon
AM
Pre dose 2 hours post 6 hours post
DAY 8 to 14
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 10 of 22
8
Tues
AM
Pre dose 1 hour post
CRP check Troponin I or T check PM
Pre dose 1 hour post
9
Wed
AM
Pre dose 1 hour post
PM
Pre dose 1 hour post
10 Thur
AM
Pre dose 1 hour post
PM
Pre dose 1 hour post
11 Fri
AM
Pre dose 1 hour post
PM
Pre dose 1 hour post
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 11 of 22
DAY 8 to 14
Cont’d
BP
Temperature
Pulse
Observations
Sitting
Standing
12 Sat
AM
Pre dose 1 hour post
PM
Pre dose 1 hour post
13 Sun
AM
Pre dose 1 hour post
PM
Pre dose 1 hour post
14 Mon
AM
Pre dose 1 hour post
PM
Pre dose 1 hour post
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 12 of 22
DAY 15 to 28
15 Tues
AM CRP check Troponin I or T check
PM
16 Wed
AM PM
17 Thur
AM PM
18 Fri
AM PM
19 Sat
AM PM
20 Sun
AM PM
21 Mon
AM PM
22 Tues
AM CRP check Troponin I or T check
PM
23 Wed
AM PM
24 Thur
AM PM
25 Fri
AM PM
26 Sat
AM PM
27 Sun
AM PM
28 Mon
AM PM
29 Tue
CRP check Troponin I or T check
57 Tue
CRP check Troponin I or T check
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 13 of 22
Clozapine Initiation Observations Information
Baseline blood pressure, pulse and temperature should be known. Observations should be taken prior to the first dose, 15 minutes after and every hour up to six hours, as a minimum, after the first dose, on DAY ONE and DAY TWO. Repeat the observations if outside the above parameters after 15 minutes. If still outside the above parameters call the doctor for advice. Only omit the dose if the doctor or pharmacist advises to do so. Observations for subsequent doses - Immediately prior to each titration dose until stabilisation.
Parameters Take action if: - Blood pressure Systolic < 100 or > 170 (Sitting and Diastolic < 60 or > 100 standing) OR a postural drop of 30mmHg Pulse > 100bpm (> 120bpm or increased by 30bpm repeat ECG) Temperature > 38.4 degrees C OR < 35.5 degrees C
APPENDIX 1
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 14 of 22
Clozapine Home Treatment Care Plan
Surname
Forenames
DOB
RT Date
Address Diagnosis
Name
Address & Contact numbers
Plan copied to
(tick) Patient
See above
See above
Main Carer
Consultant
Social Worker
CPN
GP
Others
Next of Kin
APPENDIX 2
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 15 of 22
Medication
Dose
Frequency
Indication
Issues (side effects,
concurrence etc) Clozapine (Clozaril)
Increasing dose
Daily
Antipsychotic
Patients commencing clozapine require careful monitoring. This is due to side effects which will be discussed with XXXX and their carer along with the appropriate action to be taken.
EMERGENCY CONTACT NUMBERS Home Treatment Team (HT) GP Clozaril Patient Monitoring Service (CPMS) CRISIS PLAN: Action to be taken, patient and HT team responsibilities Should XXXX develop any of the serious side effects of clozapine such as
• fever
• sore throat
• rash or other signs of infection
• extremely high pulse rate or fainting INFORM HT. TEAM Stop clozapine. Take FBC blood test. If HT are unable to respond XXXX should attend A&E department stating that clozapine is being taken, the dose, and the symptoms they are concerned about. IMMEDIATE attendance to A&E if the following side effects occur:
• seizure
• palpitations
• chest pain
• difficulty breathing
• extremely high pulse rate for a long period of time INFORM CRHT. Patient given copy of HT information sheet (please circle)
Yes
No
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 16 of 22
IDENTIFIED NEED
INTERVENTIONS
ACHIEVED
XXXX is to commence clozapine whilst in the community. To ensure safe initiation of clozapine and monitor its effects and side effects
HT team to arrange pre commencement checks and tests. As a minimum this will include WBC, LFT U&E, Cholesterol, Glucose, TFT, and an ECG, Troponin I or T, CRP. These must be carried out within 10 days of commencing clozapine. Clozapine initiation will start on a [insert day of the week] either in the patient’s own home or in a treatment suite where available. On the first 2 days XXXX will be monitored for 6 hours by CRHT staff. BP, Pulse and Temperature will be monitored pre-dose, then hourly by a RMN. XXXX will be able to be at home after the 6 hours only if agreed by the Advanced Practitioner/ SHO. If there are any concerns a Dr should be informed. A blood test will be required on Day 3 – to be arranged by CRHT. From Day 3 XXXX will be monitored at home. This will mean that a responsible adult must be with XXXX for 24 hours a day. The HT team will visit 4 times daily. Visit 1 – to take BP, pulse and Temperature and monitor any other side effects, then administer the AM dose of clozapine. HT team will then visit 2 and 6 hours after this to check BP, Pulse and Temperature. A further visit will be carried out in the evening, to check side effects and observations Day 3-7 – There will be 4 visits as described above. Day 8-14 – Observations will be required to be taken once, with there being 2 visits a day (AM & PM) Day 15-19 – One visit per day to check observations. If on stable dose and no unacceptable side effects, XXXX will be discharged from HT team and into the care of the Clozapine Clinic and their care co-ordinator. During the course of clozapine initiation, regular blood tests will be required, a minimum of once per week. These will be arranged by HT team.
Cont’d…..
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 17 of 22
IDENTIFIED NEED
INTERVENTIONS
ACHIEVED
Clozapine is known to have certain side effects, which are manageable, these are symptoms such as constipation, excessive salivation, weight gain
• XXXX to be educated regarding the common side effects of clozapine
• XXXX to be encouraged to consume a high fibre diet. Along with avoiding processed, high fat foods.
• Should constipation become an issue, XXXX to inform the team so that medical staff can review and prescribe appropriate treatment.
• Hyper-salivation (“drooling”) – This is a common side effect of clozapine and can be managed by use of other medication. XXXX to inform the team if this occurs.
• XXXX to be educated regarding healthy eating and exercise as a means for reducing/preventing weight gain. It is also important that XXXX monitors their weight and is reviewed by the medical team for signs of metabolic syndrome, whereby weight increases, along with raised cholesterol, blood glucose and blood pressure.
• Clozapine can often cause sedation. Whilst this can be difficult to combat, it is usually a temporary side effect and will diminish over time. Regular exercise, healthy eating and good sleep hygiene can help reduce the effect of sedation.
Blood tests and result monitoring: Clozapine requires regular blood monitoring – At least once per week during the first 18 weeks.
• HT team to arrange the pre clozapine blood test and ensure XXXX is registered with CPMS.
• This will enable the initial prescription of clozapine to be completed
• A further test will be required on Day 3.
• After this blood tests will be required every [insert day of the week].
• Clozapine will be prescribed on a weekly basis, assuming that the blood results are “green”
• If there is an “amber” result there must be a repeat blood test performed as soon as possible.
• If there is a “red” result, clozapine must be stopped and urgent repeat bloods taken.
• XXXX should be aware of the frequency of bloods tests and that additional tests may be required at the medical team’s request.
• Clozapine will then be released from the hospital pharmacy on a [insert day of the week]. HT team will usually arrange for this to be collected.
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 18 of 22
REVIEW Date
Comments
Patient signature: ___________________________________________________ Date: _____________________________ HT team practitioner Signature: ___________________________________________________ Date: _____________________________
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 19 of 22
COMMUNITY INITIATION OF CLOZAPINE TREATMENT PRESCRIPTION DAY 1 TO 7 (inclusive) To the Prescriber If an alternate dose to the standard CPMS recommended dose is required, the printed dose must be crossed through clearly and the
new dose written in the ‘change to’ column, each change must be initialled before the prescription is signed and dated. To Pharmacy Please dispense sufficient tablets/ liquid for the doses stated below and photocopy this prescription for your records, returning the
complete book with the medication supplied. Please label with directions or supply dose reminder card. Patient name: DOB: Result from CPMS
(include date)
DAY
DATE
MORNING DOSE
Dose administered by
Observations Completed by
EVENING DOSE
Dose administered by
Observations Completed by
CPMS dose
Change to
Initials Time Sign
CPMS dose
Change to
Initials Time Sign
Tues 1
12.5mg
NIL
Weds 2
25mg
NIL
Thurs 3
37.5mg
NIL
Fri 4
50mg
NIL
Sat 5
50mg
NIL
Sun 6
50mg
NIL
Mon 7
75mg
NIL
Prescriber signature Print name Date Bleep/ contact tel. no.
………………………………………… ………………………………………… ………………………………………… …………………………………………
PHARMACY USE ONLY Quantity supplied:
Dispensed by: 25mg tablets
Checked by: 100mg tablets
Date dispensed: Liquid 100mg/5ml
APPENDIX 3
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 20 of 22
COMMUNITY INITIATION OF CLOZAPINE TREATMENT PRESCRIPTION DAY 8 TO 14 (inclusive) To the Prescriber If an alternate dose to the standard CPMS recommended dose is required, the printed dose must be crossed through clearly and the
new dose written in the ‘change to’ column, each change must be initialed before the prescription is signed and dated. To Pharmacy Please dispense sufficient tablets/ liquid for the doses stated below and photocopy this prescription for your records, returning the
complete book with the medication supplied. Please label with directions or supply dose reminder card. Patient name: DOB: Result from CPMS
(include date)
DAY
DATE
MORNING DOSE
Dose administered by
Observations Completed by
EVENING DOSE
Dose administered by
Observations Completed by
CPMS dose
Change to
Initials Time Sign
CPMS dose
Change to
Initials Time Sign
Tues 8
50mg
50mg
Weds 9
50mg
75mg
Thurs 10
75mg
75mg
Fri 11
75mg
100mg
Sat 12
75mg
100mg
Sun 13
75mg
100mg
Mon 14
100mg
100mg
Prescriber signature Print name Date Bleep/ contact tel. no.
………………………………………… ………………………………………… ………………………………………… …………………………………………
PHARMACY USE ONLY Quantity supplied:
Dispensed by: 25mg tablets
Checked by: 100mg tablets
Date dispensed: Liquid 100mg/5ml
APPENDIX 4
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 21 of 22
COMMUNITY INITIATION OF CLOZAPINE TREATMENT PRESCRIPTION DAY 15 TO 21 (inclusive) To the Prescriber If an alternate dose to the standard CPMS recommended dose is required, the printed dose must be crossed through clearly and the
new dose written in the ‘change to’ column, each change must be initialed before the prescription is signed and dated. To Pharmacy Please dispense sufficient tablets/ liquid for the doses stated below and photocopy this prescription for your records, returning the
complete book with the medication supplied. Patient name: DOB: Result from CPMS
(include date)
DAY
DATE
MORNING DOSE
Dose administered by
Observations Completed by
EVENING DOSE
Dose administered by
Observations Completed by
CPMS dose
Change to
Initials Time Sign
CPMS dose
Change to
Initials Time Sign
Tues 15
100mg
125mg
Weds 16
100mg
150mg
Thurs 17
100mg
175mg
Fri 18
100mg
200mg
Sat 19
100mg
200mg
Sun 20
100mg
200mg
Mon 21
100mg
250mg
Prescriber signature Print name Date Bleep/ contact tel. no.
………………………………………… ………………………………………… ………………………………………… …………………………………………
PHARMACY USE ONLY Quantity supplied:
Dispensed by: 25mg tablets
Checked by: 100mg tablets
Date dispensed: Liquid 100mg/5ml
APPENDIX 5
G/TGH/HQSecs/TD/LS/Clinical procedures/Clozapine ICP. Community initiation. Version 2. Amended January 2015 22 of 22
COMMUNITY INITIATION OF CLOZAPINE TREATMENT PRESCRIPTION DAY 22 TO 28 (inclusive) To the Prescriber If an alternate dose to the standard CPMS recommended dose is required, the printed dose must be crossed through clearly and the
new dose written in the ‘change to’ column, each change must be initialed before the prescription is signed and dated. To Pharmacy Please dispense sufficient tablets/ liquid for the doses stated below and photocopy this prescription for your records, returning the
complete book with the medication supplied. Patient name: DOB: Result from CPMS
(include date)
DAY
DATE
MORNING DOSE
Dose administered by
Observations Completed by
EVENING DOSE
Dose administered by
Observations Completed by
CPMS dose
Change to
Initials Time Sign
CPMS dose
Change to
Initials Time Sign
Tues 22
100mg
250mg
Weds 23
100mg
250mg
Thurs 24
100mg
250mg
Fri 25
100mg
300mg
Sat 26
100mg
300mg
Sun 27
100mg
300mg
Mon 28
100mg
300mg
Prescriber signature Print name Date Bleep/ contact tel. no.
………………………………………… ………………………………………… ………………………………………… …………………………………………
PHARMACY USE ONLY Quantity supplied:
Dispensed by: 25mg tablets
Checked by: 100mg tablets
Date dispensed: Liquid 100mg/5ml
APPENDIX 6