Page 1

Appendix G

INDEPENDENT PRESCRIBING PROFORMA ADDITIONS FORM ADDITIONS TO PRACTICE AS AN INDEPENDENT NURSE OR PHARMACIST PRESCRIBER Name:

Title (Ms/Miss/Mrs/Mr):

Base:

Role:

Contact No:

Professional Reg Number:

Date of Birth:

Disease Area

E.g. Asthma

Evidence of Competence to prescribe for this disease area E.g. Asthma Diploma or 10 years experience (whatever is applicable)

CPD undertaken supporting prescribing within this area

State items to be prescribed and guidelines worked to, or attach protocols.

E.g. Formal updates, courses attended (whatever is applicable) Please give as much information as possible including dates attended etc.

You may list individual items or make reference to guidelines or sections of BNF. Prescribing intentions must be clear and the evidence base identified.

Please complete this form electronically, then print, sign and arrange for manager and lead clinician (mentor) to sign. Continued overleaf


Independent Prescribers Signature: …………………………………………………. Date: ………………………………… My intended scope of prescribing practice has been discussed and agreed with my manager and lead clinician (mentor). Managers Name: ………………………………………………….

Base/Contact No………………………………………

Managers Signature: ……………………………………………. Date: ……………………………

Lead Clinicians Name (Mentor): ……………………………………………. Lead Clinicians Signature (Mentor): …………………………………..

Base/Contact No…………………………………

Date: ……………………………..

Please send the completed and signed form to: Non Medical Prescribing Lead, Medicines Management Team, LCP, Beckside Court, Bradford Road, Batley, WF17 5PW

A copy should be retained by the Non Medical Prescriber and Manager.

/Independent_Pre  

http://www.kirklees.nhs.uk/fileadmin/documents/New/Public_Information/med_mgt/Locala/Independent_Prescribing_Additions_Form.doc

Read more
Read more
Similar to
Popular now
Just for you