COPY TO EACH / - Hospital Specialist
- Prescribing Team (PCIC)
- GP Records /

Prescribing of medicines recommended by hospital SPECIALISTs

PRESCRIBER / Complete this form if you are unwilling to take responsibility for prescribing medicines recommended by a hospital specialist / Please send a copy of this form to the hospital specialist, & to the
PCIC Offices–Prescribing Team, Cardiff Royal Infirmary, Glossop Terrace, Cardiff, CF24 0SZ Fax number: 02920 335200
Patient’sNHS Number:
(10 digit)
Name of consultant or other requesting specialist: / Speciality:
Hospital:
Name of Drug / Dose & Frequency / Indication / Duration of Treatment

I have been asked to accept the responsibility for prescribing this drug for the named patient, however I feel I am not in a position to do this for the following reason(s)[1]:

Please tick / 1. PRESCRIBING RESPONSIBILITY SHOULD STAY WITH THE SPECIALIST
Drug is designated ‘Hospital Only’ in the Cardiff and Vale UHB Joint Prescribing Formularyand is for specialist prescribing only.(The formulary is available at:
Drug is designated ‘Specialist Initiated’ in the Cardiff and Vale Joint Prescribing Formulary with transfer of prescribing responsibilities only occurring after the patient is stabilised on the drug.
UNLICENSED drug/dose/indication (delete as applicable) where use is not endorsed by the BNF or BNFcand/or where an approved Shared Care Protocol does not exist and the GP is unwilling to take clinical responsibility.
Please tick / 2. MONITORING BY SPECIALIST REQUIRED (SHARED CARE & NEAR PATIENT TESTING)
Drug requires regular specialist monitoring at initiation and until the patient is stabilised on the drug as indicated in the shared-care / near patient protocol. Prescribing responsibility is trying to be transferred before the patient is stabilised on the drug.
Please tick / 3. LACK OF INFORMATION / EXPERIENCE
Drug is not designated ‘Hospital Only’ (specialist prescribing only) but GP feels unable to accept clinical responsibility
(please state reasonbelow inGeneral Comments box).
Drug is NON-FORMULARY in the Cardiff and Vale UHB area. Hospital prescribers are asked not to ask GPs to initiate or continue treatment with non-formulary medicines. Includes use of medicines for other than their formulary listed indication.
Please tick / 4. PATHWAY REQUEST
Drug is included in the Cardiff and Vale UHB treatment algorithm for this condition but is being recommended before the options higher up in the pathway have been tried / considered
5. GENERAL COMMENTS / OTHER REASONS
Print Name:
…………………………………………………………. / Practice Stamp:
Signature:
………………………………………………………….
Date:
………………………………………………………….

Note: Responsibility for prescribing should not be refused on the grounds of drug cost. If this is an issue please contact the Prescribing Team (Primary Care) for advice on 02921 834537 May 2014