COMMUNITY PRESCRIPTION CHART All entries should be in CAPITAL letters and in indelible black ink. If medications/ doses are stopped, cross through the relevant line clearly to avoid error. GP: PRESCRIBER SIGNATURE LIST Name Designation Prof. reg. no. Contact details Signature ALLERGIES/ SENSITIVITIES This section must be completed before prescribing/administering any drug / STIMULUS Problem Signature Date No Known Allergies Signature Date REGULAR MEDICATION REQUIRING ADMINISTRATION Date Freq Time DOSE words and figures Route Signature Northern England Strategic Clinical Network community prescription chart v1 1
COMMUNITY PRESCIPTION CHART If medications/ doses are stopped, cross through the relevant line clearly to avoid error. AS REQUIRED (PRN) MEDICATION Date DOSE words and figures Freq Signature Stopped sig/date PAIN/ DYSPNOEA Route eg max dose 24hrs AGITATION/ DYSPNOEA Route eg max dose 24hrs NAUSEA/ VOMITING Route eg max dose 24hrs RESPIRATY SECRETIONS Route eg max dose 24hrs Route eg max dose 24hrs Northern England Strategic Clinical Network community prescription chart v1 2
COMMUNITY PRESCIPTION CHART If medications/ doses are stopped, cross through the relevant line clearly to avoid error. AS REQUIRED (PRN) MEDICATION Date DOSE words and figures Freq Signature Stopped sig/date Route eg max dose 24hrs Route eg max dose 24hrs Route eg max dose 24hrs Route eg max dose 24hrs Route eg max dose 24hrs Route eg max dose 24hrs Route eg max dose 24hrs Northern England Strategic Clinical Network community prescription chart v1 3
COMMUNITY PRESCRIPTION CHART REGULAR MEDICATION- 24 HR CONTINUOUS SUBCUTANEOUS INFUSION DILUENT SHOULD BE STERILE WATER F MOST S UNLESS SITE IRRITATION OCCURS Date DOSE words and figures Signature Stopped sig/date Water/ Saline Water/ Saline Northern England Strategic Clinical Network community prescription chart v1 4
COMPATIBILITY CHART- based on PCF 4 Changes in the law state that the instruction / direction to mix medicines must be in writing. Therefore the prescriber must indicate in the Special Instruction column which other drug(s) to mix with in the syringe driver. As a general rule, only mix two drugs per syringe. If considering using 3 or more drugs, seek specialist advice. / INDICATION : water for injection MPHINE OXYCODONE ALFENTANIL DIAMPHINE MIDAZOLAM MIDAZOLAM Seizures CYCLIZINE Nausea and vomiting METOCLOPRAMIDE HALOPERIDOL HALOPERIDOL LEVOMEPROMAZINE LEVOMEPROMAZINE HYOSCINE BUTYLBROMIDE Chest secretions / Colic pain HYOSCINE HYDROBROMIDE Chest secretions Per 24hrs Use conversion ratio if on regular opioids 5mg (increase by 30-50% at a time) 5mg, no upper limit (increase dose by 30-50% at a time) 0.5mg (increase by 30-50% at a time) 5mg, no upper limit (increase dose by 30-50% at a time) 10mg (Increase by 30-50%) DOSE > 30mg 10mg 150mg Dilute as much as possible with water (skin irritation) 30-120mg (Dilute high doses as much as possible) PRN (Doses normally 1 hour apart, seek specialist advice if symptom control not being achieved) morphine oxycodone 250 500 microg alfentanil diamorphine COMPATIBILITY- 2 SYRINGE DRIVER YES- NOT COMPATIBLE or QUERY COMPATIBLE COMPATIBLE Alfentanil 50mg 10mg (low concentration) Morphine Alfentanil Morphine 1.5-5mg 1.5mg Alfentanil 5-30mg 1.5mg Hyoscine butlybromide 6.25-12.5mg 6.25mg Alfentanil 12.5-200mg 12.5mg Hyoscine butlybromide (Dilute high doses as much Morphine as possible) 60-120mg 20mg Alfentanil Morphine 1.2-2.4mg 400microg Morphine - incompatible at high concentration equal to or > 2mg/ml - some reports incompatible at high doses (mixes at usual concentrations) - ( + is a problematic combination therefore be cautious, dilute to 23mls and monitor). - 60mg max is 150mg/23mls - > 60mg max is 50mg/23ml - (Alfentanil high concentration) -Hysocine hydroromide no data - ( high concentration) - incompatible at high concentration (may precipitate if >2mg/ml) -Always inspect solution and discard if cloudy / crystalised -Beware with high doses -Morphine some reports incompatible at high doses of (mixes at usual concentration) - some reports incompatible -Alfentanil high concentration incompatible - high concentration incompatible - incompatible - not recommended - not recommended - some reports incompatible - (see oxycodone section) - not recommended - not recommended - not recommended - not recommended - no data - (see diamorphine section) - not recommended - no data -Morphine (see morphine section) - not recommended - not recommended - not recommended - incompatible - not recommended -Hyoscine Hydrobromide not recommended -Alfentanil no data - not recommended - not recommended Northern England Strategic Clinical Network community prescription chart v1 5