Fax This Referral to GP for Ongoing Prescription of Dalteparin

Doncaster and Bassetlaw Area Prescribing Committee Approved March 2012

APPENDIX 2

DALTEPARIN SHARED CARE PROFORMA

Fax this referral to GP for ongoing prescription of dalteparin

according to the Doncaster Dalteparin Shared Care Protocol

Not to be used for surgical patients being discharged on extended prophylaxis

Fax this form to DBHFT anticoagulation clinic for

HIT monitoring as outpatient if required – see below

Hospital to provide initial 28 day supply of dalteparin and to complete heparin induced thrombocytopenia (HIT)monitoring (full blood count on day 5, 6 or 7 and day 12, 13 or 14). GP to continue prescribing and carry out further monitoring as appropriate. Patient’s medical care remains with the hospital consultant who initiated dalteparin. Refer to Consultant Haematologist for further thrombosis care where appropriate. Fax number 01302 381487

1) REFERRING CONSULTANT

Referring consultant______DRI [ ]BDGH [ ]

Consultant contact number______Fax number: ______

Next consultant clinic appointment ______GP/practice receiving referral______

2) INDICATION FOR DALTEPARIN

a) Thromboprophylaxis: In pregnancy Central line Cancer

b) Deep vein thrombosis/ Pulmonary embolism:In pregnancy Injectable drug user

Associated with cancer/ cancer therapies Unsuitable for oral anticoagulation

3) TREATMENT INFORMATION

Patient’s weight______(kg) Dose of dalteparin______units ONCE/TWICE daily (delete as appropriate)

Date started ______

Intended dose changes (if applicable):

Dose to change to ______units ONCE/TWICE daily (delete as appropriate) on (date) ______

Proposed duration of treatment: 6 weeks 3 months 6 months 

Other duration (please give details):______

Dalteparin to be administered by: Patient or carer District Nurse (fax this form along with DN referral)

Further relevant information (clinical problems, concurrent medication):

4) MONITORING REQUIREMENTS

Is monitoring for hyperkalaemia required (see full protocol for guidance)? Yes No

Baseline results:Creatinine:______(μmol/L)eGFR______(mls/min/1.73m2)

Platelets:______(x109/ Potassium:______(mmol/L)

Heparin induced thrombocytopenia (HIT) monitoring is complete

or

DBHFT Anticoagulation Clinic to complete HIT monitoring (fax this form to 01302 381487 to make referral)

Form completed by:

Signature: ______Print name______

Designation: ______Contact No.(bleep/ext.): ______Date: ______

Faxed by:______Time: ______Date: ______

Received at GP practice by:______Time: ______Date: ______

(sign and fax back to sender to confirm referral has been received)

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immediately and return in the post to us. If the reader of this fax is not the intended recipient you are hereby notified that any distribution or

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