SUBCUTANEOUS SYRINGE PUMP PRESCRIPTION RECORD DNS1 SP

PRESCRIBER: EXACT DOSAGES should be prescribed in syringe pump, no ranges permissible.

It is not necessary to rewrite the syringe pump prescription every day, unless the drugs or doses change.

If the prescription changes, cross out the prescription completely and rewrite it in the next numbered box.

The first line diluent is water for injection.

ADMINISTRATOR: All medications prescribed must be administered. A separate syringe pump monitoring form must be used.

Information regarding the compatibility of mixtures of drugs in the syringe can be obtained from the latest version of the Palliative Care Formulary or at

Please contact specialist advice at Hayward House on (0115) 9691169 ext 57079 if:

  • There is a doubt regarding the compatibility of a mixture
  • The patient develops a site reaction
  • Contents of the syringe/line appear cloudy/crystalline/change colour
  • If volume in a syringe is greater than 20mls (drug and diluent)

USE NEW PRESCRIPTION BOX WHEN DOSE OR MEDICATION IS CHANGED

Prescription Number 1 / Include all drugs prescribed in one pump / Prescription Number 2 / Include all drugs prescribed in one pump
Medication / Dose / Medication / Dose
Diluent / dURATION
24 Hours / Diluent / dURATION
24 Hours
Doctor’s NAME AND SIGNATURE / DATE / Doctor’s NAME AND SIGNATURE / DATE
Stopped by / DATE / NEW PRESRIPTION TO START (circle)
ASAP or when next due / Stopped by / DATE / NEW PRESRIPTION TO START (circle)
ASAP or when next due
TIME / TIME
Prescription Number 3 / Include all drugs prescribed in one pump / Prescription Number 4 / Include all drugs prescribed in one pump
Medication / Dose / Medication / Dose
Diluent / dURATION
24 Hours / Diluent / dURATION
24 Hours
Doctor’s NAME AND SIGNATURE / DATE / Doctor’s NAME AND SIGNATURE / DATE
Stopped by / DATE / NEW PRESRIPTION TO START (circle)
ASAP or when next due / Stopped by / DATE / NEW PRESRIPTION TO START (circle)
ASAP or when next due
TIME / TIME