Pharmacy First Emergency Supply Consultation ProForma Sample Clauses

Pharmacy First Emergency Supply Consultation ProForma. Date of Supply Date entered onto PharmOutcomes Time of Supply Client Address Client name Postcode GP surgery Date of birth NHS number (if known) Patient consent? Yes No Name of person making supply: Pharmacist on duty GPhC number Medication supplied – Please make a note of drug, form and quantity. Medication 1 supplied Medication 2 supplied Medication 3 supplied Medication 4 supplied Medication 5 supplied If more than 5 meds supplied - complete a second consultation form. NHS Levy Paid? Yes / No Where patient exempt: Evidence Seen? Yes / No No of Levies collected Where was patient referred from? NHS111 GP Practice A&E, WIC or OOH Pharmacy Word of mouth Other (explain) Without pharmacy service, where would you have attended? A&E GP Practice Out Of Hours Walk in Centre (WIC) Gone without meds Other (explain) Nature of Emergency (why request made) Patient lost/misplaced meds Patient ran out of meds Patient away from home Rx not available from GP Other (explain) How often has this happened in the last year? Not at all Once or twice 3 – 6 times More than 6 times If patient ran out of meds, when was Rx ordered? Less than 2 days 2 – 4 days 5-7 days More than 7 days Who normally orders the repeat Rx for the patient? Patient Carer (family/friend) Xxxxx (formal) Pharmacy Other (explain) Would have gone to OOH Other: Do meds run out at different times? Yes / No Are any of meds requested new to you? Yes / No Is repeat ordering system understood? completely Fairly well partially Not at all N/A Is support to manage meds better needed from? None/ N/A Carer (family/friend) Xxxxx (formal) Pharmacy GP Other (explain) PharmOutcomes will notify patient’s GP prac - where no xxx.xxx email available you will be prompted by the system to manually inform GP. Patients who don’t have to pay must fill in parts 1 and 3. Those who pay must fill in parts 2 and 3.