rtms (repetitive Transcranial Magnetic Stimulation) Referral Documentation Treatment Centre, Berrywood Hospital, Northampton / 91

Transcription

1 rtms (repetitive Transcranial Magnetic Stimulation) Referral Documentation Centre, Berrywood Hospital, Northampton / 91 ; Centre.Berrywood@nhft.nhs.uk

2 Contents Medical Staff Documentation Page 1 Checklist for medical staff in preparing a patient for rtms 3 2 Integrated Care Pathway (ICP) for rtms 4 3 Inclusion and Exclusion Criteria for rtms 5 4 Amended DOH Consent Form 6 5 Patient Letter Information for all patients 7 6 rtms Referral 8 7 rtms prescription and treatment record 13 Nursing Documentation 1 Guidance for staff preparing patients for rtms 19 2 rtms nursing care plan 20 Centre Documentation 1 Pre rtms assessment 30 2 rtms checklist 31 3 rtms observations 39 4 rtms patient discharge 42

3 Checklist for Medical Staff in preparing a patient for rtms Please tick Yes No 1. Has the patient been consented for rtms? 2. In preparation for rtms have the following been discussed and documented: Discussed rtms procedure Carer / advocate informed Risks and Benefits of rtms explained Have you reminded the patient that they can withdraw consent at any time An explanation regarding the risks of not having rtms and other treatment alternatives Patient s rights including access to independent advocacy No pressure / coercion put on the patient s decision 4. Have you completed: Prescription Chart rtms Patient Screening Form 5. If travelling from a remote site has a letter to confirm the patient s fitness to travel been completed by the referring Consultant or nominated doctor ENSURE CLINICAL STATUS OF THE PATIENT IS ASSESSED WEEKLY BY THE REFERRING TEAM Name: Signature: Designation:

4 2.2 Integrated Care Pathway for rtms If the patient has capacity and refusing treatment rtms cannot be given Identified need for rtms. Consultant determines capacity to consent to treatment Refer to the rtms team on / 91 (24 hour answer machine) or treatment.centre@nhft.nhs.uk Key Referring Team rtms team rtms Consultant Written and verbal information given to patient / carers. Send out rtms screening form to patient for completion. Obtain informed consent and complete DOH consent form Preparation by referring team including medical history, physical examination, investigations, cognitive assessments and arrange visit to dept. as required. rtms Team patient assessment rtms prescription Patient withdraws consent, advise referring team Pre rtms checklist rtms Procedure Reassess treatment plan rtms team complete treatment documentation Consider alternatives Reassess treatment plan Next treatment

5 Inclusion / Exclusion Criteria for rtms Inclusion Criteria Adults over the age of 18 Gender: both Diagnosis of Depressive Disorder (DSM IV) Diagnosis of Anorexia, Cocaine addiction, Nocturnal Enuresis, Anxiety Exclusion Criteria Patients able to give informed consent Previous response to ECT but where the patient is unwilling or unable to have ECT Previous response to rtms Inpatient or out patient Patients from referring hospitals where an SLA is in place. Private patients HAM-D <25 if HAM-D >25 please refer to Lead rtms Consultant History of Bipolar disorder. Previous or current history of seizures or epilepsy Actively suicidal Preponderance of anxiety symptoms History of or potential alcohol withdrawal Current alcohol / stimulant dependence with propensity for toxic /withdrawal seizures. Major unstable medical disorder Cardiac pacemaker or implanted medication pump. Clinically relevant neurological co morbidity such as brain neoplasm, cerebral vascular events Metal objects in and around the body which cannot be moved. Pregnancy / Cochlear implant

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7 Consent Form 1 Patient details (or pre-printed label) Patient Agreement to repetitive Transcranial Magnetic Stimulation (rtms) NHS Organisation:... Patient s first names:... Patient s surname/family name:... Date of Birth:... Male Female Responsible health professional:... Job Title:.. NHS number (or other identifier)... Special Requirements (e.g. other language / other communication method): Proposed course of treatment: rtms for Depression / Anxiety rtms rescue treatment UP TO A MAXIMUM COURSE OF FORTY TREATMENT SESSIONS Further consent is required for a longer course of treatment. Capacity to consent to be determined by Referring Consultant and appropriate entry to that effect entered in the clinical notes. Statement of health professional (to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in consent policy) I have explained the procedure to the patient. In particular, I have explained: Approximately 33% patients achieve remission, 33% show a response and 33% do not respond. The intended benefits... Frequently occurring temporary side-effects: headache, tiredness, mild scalp tingling and sensitivity, scalp discomfort, scalp burn, tinnitus, hearing loss. Other serious risks that can occur: seizure (1:30,000). I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments and any particular concerns of this patient. I have discussed the likely consequence of having no rtms treatment. The following written information has been provided..... Name (Print):... Job Title: Contact details (if patient wishes to discuss options later)... Statement of interpreter (where appropriate) I have interpreted the information above to the patient to the best of my ability and in a way in which I believe she/he can understand. Signed... Date... Name (PRINT)... GOLD COPY: CASE NOTES WHITE COPY: PATIENT Copy accepted by patient: yes / no (please circle)

8 Statement of patient Patient identifier/label Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy, which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask we are here to help you. You have the right to change your mind at any time, including after you have signed this form. I agree to the procedure or course of treatment described on this form namely repetitive Transcranial Magnetic Therapy (rtms). I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience. I understand that I will have the opportunity to discuss the details with a healthcare professional before the procedure. I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or prevent serious harm to my health. I have been told about additional procedures, which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion I understand that I will be asked to confirm consent before every session. Patient s signature... Date... Name (PRINT)... A witness should sign below if the patient is unable to sign but has indicated his or her consent... Name (Print):... Confirmation of consent (to be completed by a health professional when the patient is admitted for the procedure, if the patient has signed the form in advance). On behalf of the team treating the patient, I have confirmed with the patient that he/she has no further questions and wishes the procedure to go ahead... Name (Print):.... Job Title: Important notes: (tick if applicable) See also advance rtms/living will (e.g. Jehovah s Witness form) Patient has withdrawn consent (ask patient to sign/date here)... Patient consent obtained to access system 1 / health records via GP

9 Centre for Neuromodulation Berrywood Hospital Berrywood Drive Duston Northampton NN5 6UD Tel: /91 Date; INFORMATION FOR ALL PATIENTS You have been referred for rtms by. The Centre for Neuromodulation will be responsible for the delivery of treatment and will keep the treating team, GP, clinician informed as to your progress and any risk issues that may emerge during treatment. Please be advised that the Centre for Neuromodulation will NOT take on care co-ordination and/or alter your treatment plan in respect of medication or other physical/psychological interventions. The Centre for Neuromodulation is responsible for the care and administration relating to rtms only. Overall care remains with your referring team/ Consultant. Should you require any additional support during treatment, please refer to your CRISIS plan and your referring Consultant. Yours sincerely Dr Alex O'Neill-Kerr MBChB, FCPsych (SA), FRCPsych Consultant Psychiatrist Medical Director Northamptonshire Healthcare NHS Foundation Trust Berrywood Hospital, Northampton, NN5 6UD centreforneuromdulation.com

10 rtms Patient Screening Form This should be completed by the patient / patient representative. Please complete the following information: Yes Please Tick No 1. Have you had rtms before and had any adverse effects? 2. Do you have epilepsy or ever had a convulsion or a seizure? 3. Does anyone in your family suffer from epilepsy? 4. Have you ever had a stroke? 5. Have you ever had a serious head injury? (Including loss of consciousness, neurosurgery or a brain related condition or illness that caused brain injury?) 6. Have you ever had an electroencephalogram (EEG)? 7. Have you ever been a machinist, welder or metal worker? 8. Have you ever had a facial injury from metal / metal removed from Your eyes? 9. Have you ever had complications from an MRI? 10. Have you had any surgery in the last 12 months above the neck? 11. Have you ever had a surgical procedure to your spinal cord? 12. Do you have spinal problems? 13. Do you have a history of fainting? 14. Do you suffer from frequent headaches? 15. Do you have any hearing problems or ringing in your ears? (Advise earplugs must be worn as possible risk of temporary tinnitus) 16. Do you have a medication infusion device? 17. Are you taking prescribed medication or recreational drugs? Please specify: 18. Are you pregnant? (N.B. Complete pregnancy test for women of childbearing age) 19. Last Menstrual Period? 20. How much alcohol do you drink in an average week? Units: Height: Weight: BMI:

11 Have you ever had or currently have the following: Please tick 1. Aneurysm clips or coils 2. Cardiac pacemaker or wires 3. Internal cardioverter defibrillator (ICD) 4. Carotid or cerebral stents 5. Deep brain stimulator 6. Metallic devices implanted in your head 7. Dental implants 8. Cochlear implants/ear implants 9. CSF (cerebrospinal fluid) shunt 10. Eye Implants 11. Cardiac stents, filters or metallic valves 12. Tattoo 13. Vagus nerve stimulator (VNS) 14. Blood vessel coil 15. Shrapnel, bullets, pellets, BBs, other metal fragments 16. Wearable cardioverter defibrillator 17. Implanted insulin pump 18. Programmable shunt or valve 19. Hearing aid 20. Cervical fixation devices 21. Surgical clips, staples or sutures 22. VeriChip microtransponder 22. Wearable monitor (e.g. heart monitor) 23. Bone growth stimulator 24. Wearable infusion pump 25. Radioactive seeds 26. Portable glucose monitor 27. Tracheostomy 28. Medication patch/nicotine patch Other implanted metal or device If yes please specify.. Yes No If you have answered yes to any of the above please provide further information: Signature of patient/patient representative. Date.. Signature of Consultant Psychiatrist/rTMS Lead Nurse.. Date..

12 rtms REFERRAL Patient Details Name: Date of Birth: Age: Ward/OP Sector: Ethnic Origin: Consultant: Completing Doctor: Patients preferred language: Patient Diagnosis at referral (please state); Is the patient fit to travel to and from rtms? Please circle Yes / No N.B. ADVISE FOR 1 st TREATMENT FOR PATIENT NOT TO DRIVE AND TO HAVE AN ESCORT / CARER Reason for Referral (including current presentation) Psychiatric History (please detail current / historical risks)

13 Past Medical/Surgical History (Please include previous operations / including metal adjuncts) Current Medications & Allergies Please list ALL medications Pre rtms Cognitive Status Becks Depression Inventory: Hamilton Depression Rating Scale (21 item): Clinical Global Impression: QIDS: Other assessments (i.e. GAD): Care Pathway for rtms Is the patient capacious and consenting to treatment? Please circle Yes / No NB. CONSENT FORM TO BE COMPLETED BY CONSULTANT ONLY Patients measurements Circumference of head Size of Cap Used Date assessed / sign cms cms

14 NOTES TO THE PRESCRIBER An amended Department of Health (DOH) consent form 1 must be completed fully and attached. Copy given to patient. Please follow local protocol / guidelines for preparation prior to rtms. Patient information letter on Page 9 given to patient. All medication should be taken as prescribed on the morning of treatment. No more than 10 rtms treatments are to be prescribed at one time. Prescriptions can be electronic via system 1. Review of the patient is two weekly or before as necessary. rtms prescription is the responsibility of the referring consultant. rtms cannot be given without an up to date prescription (valid for 14 days). Pre-rTMS assessment documentation must be filled out in full. All day patients require an escort for their initial treatment session and advised not to drive so to assess the patient s initial response to treatment. If the patient experiences no untoward effects for consequent treatments patients will be able to drive and attend routine appointments unaccompanied. Guidance will be given regarding contact in case of emergency / out of hours support. RC to discuss and document fitness to drive to and from appointments as necessary.

15 Px Chart for Inhibitory rtms Tx No. Px Date Dose side (RDLPFC) site (F3 or F5) frequency (hz) Total no of Pulses Signed Px cancelled

16 rtms Chart Tx No. Date administered Dose Administered side (RDLPFC) site (F3 or F5) No of times coil repositioned Side effects / concerns reported Signed

17 Px Chart for rtms for Depression Tx No. Px Date Dose side (LDLPFC) site (F3 or F5) frequency (hz) Total no of Pulses Signed Px cancelled

18 rtms Chart Tx No. Date administered Dose Administered side (LDLPFC) site (F3 or F5) No of times coil repositioned Side effects / concerns reported Signed

19 Px Chart for rtms for Depression Tx No. Px Date Dose side (LDLPFC) site (F3 or F5) frequency (hz) Total no of Pulses Signed Px cancelled

20 rtms Chart Tx No. Date administered Dose Administered side (LDLPFC) site (F3 or F5) No of times coil repositioned Side effects / concerns reported Signed

21 Px Chart for rtms for Depression Tx No. Px Date Dose side (LDLPFC) site (F3 or F5) frequency (hz) Total no of Pulses Signed Px cancelled

22 rtms Chart Tx No. Date administered Dose Administered side (LDLPFC) site (F3 or F5) No of times coil repositioned Side effects / concerns reported Signed

23 Nursing Documentation Guidelines for staff preparing patients for rtms Physical medications to be given pre rtms on advice of referring team or rtms Consultant. Staff to ensure patient is wearing an identification band. Please ensure the patient is wearing a red band if they have any allergies. Inpatients to be escorted to Centre by a qualified escort. If the qualified nurse delegates this responsibility to a healthcare care assistant then the qualified nurse retains the responsibility and accountability for patient care. The patient should be offered the opportunity to complete information on their experience on how beneficial they are finding the treatment. This should be completed after each rtms treatment and any concerns relayed to the treatment centre team. Review weekly at ward round. Any concerns / progress again feedback to the treatment centre team. If rtms treatment is to continue then the referring team to ensure that the prescription card is completed and valid.

24 rtms Nursing Care Plan Patient s name... Date of birth... Date formulated... Preferred Language... Identified patient need Aims or expected outcomes: Patient s perception of proposed treatment: Staff involved in escort duties should know the patient, be clear about their responsibilities and understand any physical or / and medical conditions that may be relevant. Importantly the escorts must understand what is expected of them in the case of a psychiatric / medical crisis at or on the way to and from the Centre; or if the patient attempts to leave the escorting staff. Signed by (nurse)... patient... Date... Inform Centre re proposed treatment.

25 Explain the procedure for rtms treatment to patient / relatives / carer as appropriate. Ensure relevant documentation is completed (e.g. rtms referral) and that rtms is prescribed. A nursing care plan must be documented. On the morning of rtms, identify and ensure nurse escort (who is known to the patient) is aware of patient s legal status and of the proposed treatment. On patient s return to ward monitor condition. Record treatment and relevant information in patient notes / epex. Inform referring team and Centre of untoward effects of rtms. Ensure patient is reviewed every week or before as necessary. Other comments

26 Evaluation of Individual Care Plan Tx No. Evaluation Each entry must be signed including designation Date / Signed

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28 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

29 Please can you ensure the following is completed: Centre (TC) Staff Documentation Pre rtms Assessment 1 Are all the patient s details registered on System One 2 Have you requested permission to access GP records and documented on System One 3 GP Informed 4 Have you obtained previous rtms treatment details (if req.) 5 Information guide to rtms given 6 Information given about independent advocacy 7 Time given to patient to ask if they have all the information they need 8 Check rtms prescription chart no more than 10 signed 9 Pre Cognitive Assessments completed 10 Detailed medical history 11 Physical Examination completed 12 Patient s BMI check due to weight on trolley or chair 13 Check working with risk assessment up to date and available for staff 14 Carers Assessment (as required) 15 Moving and Handling Assessment 16 Waterlow Scale 17 CALS 18 Current medication list 19 Patient Transport / Escort / Fitness to travel discussed 20 Pain relief medication discussed 21 Patient access to media facilities during treatment 22 Advance decision 23 Pregnancy Test 24 Spiritual needs 25 Dietary needs 26 Hearing Aids / Glasses 27 Discussed removing Jewellery / Mobile phones / Cards prior to rtms Comments / Action Taken: Yes No Date / signed: Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

30 Centre rtms Checklist Date of Birth: Patient s Name: Legal Status: No: Patient s identity checked DOH consent form signed rtms prescription chart completed in full and valid e-pex records / Notes and current medication chart available Current medication list available Prescribed pain relief administered (as necessary) Remove magnetic sensitive objects (I.e. jewellery, credit cards, mobile phones, contact lenses, etc.) Remove glasses and hearing aids Opportunity given to empty bladder Patient introduced to staff present Any changes in physical health since last treatment? (Report these to rtms Cons) Any side effects or problems since last treatment? (Report details to referring team) Patient s Clinical Status reviewed every two weeks or before as necessary Checks completed by: Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal witnessed and signed by 2 members of staff). Tx 1 Tx 2 Tx 1 Tx 2 Tx 3 Tx 4 Tx 3 Tx 4 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

31 Centre rtms Checklist Date of Birth: Patient s Name: Legal Status: No: Patient s identity checked DOH consent form signed rtms prescription chart completed in full and valid e-pex records / Notes and current medication chart available Current medication list available Prescribed pain relief administered (as necessary) Remove magnetic sensitive objects (I.e. jewellery, credit cards, mobile phones, contact lenses, etc.) Remove glasses and hearing aids Opportunity given to empty bladder Patient introduced to staff present Any changes in physical health since last treatment? (Report these to rtms Cons) Any side effects or problems since last treatment? (Report details to referring team) Patient s Clinical Status reviewed every two weeks or before as necessary Checks completed by: Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal witnessed and signed by 2 members of staff). Tx 5 Tx 6 Tx 5 Tx 6 Tx 7 Tx 8 Tx 7 Tx 8 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

32 Centre rtms Checklist Date of Birth: Patient s Name: Legal Status: No: Patient s identity checked DOH consent form signed rtms prescription chart completed in full and valid e-pex records / Notes and current medication chart available Current medication list available Prescribed pain relief administered (as necessary) Remove magnetic sensitive objects (I.e. jewellery, credit cards, mobile phones, contact lenses, etc.) Remove glasses and hearing aids Opportunity given to empty bladder Patient introduced to staff present Any changes in physical health since last treatment? (Report these to rtms Cons) Any side effects or problems since last treatment? (Report details to referring team) Patient s Clinical Status reviewed every two weeks or before as necessary Checks completed by: Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal witnessed and signed by 2 members of staff). Tx 9 Tx 10 Tx 9 Tx 10 Tx 11 Tx 12 Tx 11 Tx 12 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

33 Centre rtms Checklist Date of Birth: Patient s Name: Legal Status: No: Patient s identity checked DOH consent form signed rtms prescription chart completed in full and valid e-pex records / Notes and current medication chart available Current medication list available Prescribed pain relief administered (as necessary) Remove magnetic sensitive objects (I.e. jewellery, credit cards, mobile phones, contact lenses, etc.) Remove glasses and hearing aids Opportunity given to empty bladder Patient introduced to staff present Any changes in physical health since last treatment? (Report these to rtms Cons) Any side effects or problems since last treatment? (Report details to referring team) Patient s Clinical Status reviewed every two weeks or before as necessary Checks completed by: Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal witnessed and signed by 2 members of staff). Tx 13 Tx 14 Tx 13 Tx 14 Tx 15 Tx 16 Tx 15 Tx 16 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

34 Centre rtms Checklist Date of Birth: Patient s Name: Legal Status: No: Patient s identity checked DOH consent form signed rtms prescription chart completed in full and valid e-pex records / Notes and current medication chart available Current medication list available Prescribed pain relief administered (as necessary) Remove magnetic sensitive objects (I.e. jewellery, credit cards, mobile phones, contact lenses, etc.) Remove glasses and hearing aids Opportunity given to empty bladder Patient introduced to staff present Any changes in physical health since last treatment? (Report these to rtms Cons) Any side effects or problems since last treatment? (Report details to referring team) Patient s Clinical Status reviewed every two weeks or before as necessary Checks completed by: Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal witnessed and signed by 2 members of staff). Tx 17 Tx 18 Tx 17 Tx 18 Tx 19 Tx 20 Tx 19 Tx 20 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

35 Centre rtms Checklist Date of Birth: Patient s Name: Legal Status: No: Patient s identity checked DOH consent form signed rtms prescription chart completed in full and valid e-pex records / Notes and current medication chart available Current medication list available Prescribed pain relief administered (as necessary) Remove magnetic sensitive objects (I.e. jewellery, credit cards, mobile phones, contact lenses, etc.) Remove glasses and hearing aids Opportunity given to empty bladder Patient introduced to staff present Any changes in physical health since last treatment? (Report these to rtms Cons) Any side effects or problems since last treatment? (Report details to referring team) Patient s Clinical Status reviewed every two weeks or before as necessary Checks completed by: Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal witnessed and signed by 2 members of staff). Tx 21 Tx 22 Tx 21 Tx 22 Tx 23 Tx 24 Tx 23 Tx 24 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

36 Centre rtms Checklist Date of Birth: Patient s Name: Legal Status: No: Patient s identity checked DOH consent form signed rtms prescription chart completed in full and valid e-pex records / Notes and current medication chart available Current medication list available Prescribed pain relief administered (as necessary) Remove magnetic sensitive objects (I.e. jewellery, credit cards, mobile phones, contact lenses, etc.) Remove glasses and hearing aids Opportunity given to empty bladder Patient introduced to staff present Any changes in physical health since last treatment? (Report these to rtms Cons) Any side effects or problems since last treatment? (Report details to referring team) Patient s Clinical Status reviewed every two weeks or before as necessary Checks completed by: Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal witnessed and signed by 2 members of staff). Tx 25 Tx 26 Tx 25 Tx 26 Tx 27 Tx 28 Tx 27 Tx 28 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

37 Centre rtms Checklist Date of Birth: Patient s Name: Legal Status: No: Patient s identity checked DOH consent form signed rtms prescription chart completed in full and valid e-pex records / Notes and current medication chart available Current medication list available Prescribed pain relief administered (as necessary) Remove magnetic sensitive objects (I.e. jewellery, credit cards, mobile phones, contact lenses, etc.) Remove glasses and hearing aids Opportunity given to empty bladder Patient introduced to staff present Any changes in physical health since last treatment? (Report these to rtms Cons) Any side effects or problems since last treatment? (Report details to referring team) Patient s Clinical Status reviewed every two weeks or before as necessary Checks completed by: Patient confirming consent before each treatment (2 signatures each time; the patient and the nurse / healthcare professional confirming consent or verbal witnessed and signed by 2 members of staff). Tx 29 Tx 30 Tx 29 Tx 30 Tx Tx Tx Tx Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

38 rtms Patient Observations Pre rtms Post rtms Date / time Blood Pressure Pulse Sats Completed by Date / Time Blood Pressure Pulse Sats Completed by Tx 1 Tx 2 Tx 3 Tx 4 Tx 5 Tx 6 Tx 7 Tx 8 Tx 9 Tx 10 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

39 rtms Patient Observations Pre rtms Post rtms Date / time Blood Pressure Pulse Sats Completed by Date / Time Blood Pressure Pulse Sats Completed by Tx 11 Tx 12 Tx 13 Tx 14 Tx 15 Tx 16 Tx 17 Tx 18 Tx 19 Tx 20 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

40 rtms Patient Observations Pre rtms Post rtms Date / time Blood Pressure Pulse Sats Completed by Date / Time Blood Pressure Pulse Sats Completed by Tx 21 Tx 22 Tx 23 Tx 24 Tx 25 Tx 26 Tx 27 Tx 28 Tx 29 Tx 30 Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

41 rtms Patient Discharge - To be completed on patient being discharged - I confirm that I have read and understood the following information / guidelines post rtms: No Patient signed: Carer 1 Discharged by (print and sign): Date/Time: Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

42 rtms Patient Discharge - To be completed on patient being discharged - I confirm that I have read and understood the following information / guidelines post rtms: No Patient signed: Carer Discharged by (print and Date/Time: sign): Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018

43 rtms Patient Discharge - To be completed on patient being discharged - I confirm that I have read and understood the following information / guidelines post rtms: No Patient signed: Carer Discharged by (print and Date/Time: sign): Copyright Northamptonshire Healthcare NHS Foundation Trust All rights reserved. Review April 2018