Record. This Document Should Remain with the Patient

Surname: / Forename:
Date of Birth: / NHS No:
STJH No: / Origin of chart:
Confidentiality Classification
C1 Non-confidential
C2 Restricted int. circulation / ü
C3 Restricted ext. circulation / ü

When transferring care confirm current drugs & doses using syringe pump infusion administration

record. This document should remain with the patient.

Surname: / Forename:
Date of Birth: / NHS No:
STJH No: / Origin of chart:
Allergies and adverse drug reactions:
CONTACT ST JOSEPH’S HOSPICE FOR ADVICE AS REQUIRED ON 0208 525 6000 – when commencing a syringe pump please start at the lower end of the range.
Pain Dose range:(Consider prescribing in increments based on current requirements)
Date: / Medication: / Dose range: / Prescriber sign and print:
Nausea / Vomiting
Date: / Medication: / Dose range: / Prescriber sign and print:
Agitation / Distress
Date: / Medication: / Dose range: / Prescriber sign and print:
Respiratory tract secretions
Date: / Medication: / Dose range: / Prescriber sign and print:
Other medication - specify indication here:
Date: / Medication: / Dose range: / Prescriber sign and print:
Other medication - specify indication here:
Date: / Medication: / Dose range: / Prescriber sign and print:
DILUENT
Date: / Medication: / Prescriber sign and print:

AS REQUIRED PRN SUBCUTANEOUS MEDICATION

Allergies and adverse drug reactions:
Pain / Date:
Medication: / Time:
Dose range:
/ Max frequency or
max 24hr dose:
/ Subcut / Dose:
Prescriber sign,
print & date: /
/ Signed:
Nausea / Vomiting / Date:
Medication: / Time:
Dose range:
/ Max frequency or
max 24hr dose:
/ Subcut / Dose:
Prescriber sign,
print & date: /
/ Signed:
Agitation / Distress / Date:
Medication: / Time:
Dose range:
/ Max frequency or
max 24hr dose:
/ Subcut / Dose:
Prescriber sign,
print & date: /
/ Signed:
Respiratory tract secretions / Date:
Medication: / Time:
Dose range:
/ Max frequency or
max 24hr dose:
/ Subcut / Dose:
Prescriber sign,
print & date: /
/ Signed:
Other – specify indication / Date:
Medication: / Time:
Dose range:
/ Max frequency or
max 24hr dose:
/ Subcut / Dose:
Prescriber sign,
print & date: /
/ Signed:
Other – specify indication / Date:
Medication: / Time:
Dose range:
/ Max frequency or
max 24hr dose:
/ Subcut / Dose:
Prescriber sign,
print & date: /
/ Signed:

SYRINGE DRIVER ADMINISTRATION RECORD

If more than one syringe pump is in use, complete a separate checklist for each syringe pump
Clearly label each checklist to identify it to its syringe pump, as follows:
Pump supplied by: Syringe pump make and model; Syringe pump serial number; Date of last service (if known).
Date:
Time:
Diluent:
/ Medications: / Dose in syringe: / Batch: / Expiry: / Sign & print:
1
2
3 / Tick box to confirm additive label attached to syringe
4
Date:
Time:
Diluent:
/ Medications: / Dose in syringe: / Batch: / Expiry: / Sign & print:
1
2
3 / Tick box to confirm additive label attached to syringe
4
Date:
Time:
Diluent:
/ Medications: / Dose in syringe: / Batch: / Expiry: / Sign & print:
1
2
3 / Tick box to confirm additive label attached to syringe
4
Date:
Time:
Diluent:
/ Medications: / Dose in syringe: / Batch: / Expiry: / Sign & print:
1
2
3 / Tick box to confirm additive label attached to syringe
4
Date:
Time:
Diluent:
/ Medications: / Dose in syringe: / Batch: / Expiry: / Sign & print:
1
2
3 / Tick box to confirm additive label attached to syringe

MEDICATION STOCK BALANCE

Medication: / Form: / Strength:
Opening stock balance transferred from page no: / This page no:
Date: / Time: / Opening stock balance received into stock
(no. ampoules) / Dose given
(milligram/ microgram): / Wasted
(milligram/ microgram): / Closing stock balance/ amount removed for disposal
( no. ampoules): / Sign & print:
Registrant / Witness
Closing stock balance transferred to new balance chart. Page No: / Sign & print:
OR
Closing stock balance disposed of – enter details of disposal in patient notes. / Sign & print:

MEDICATION STOCK BALANCE Cont’d

COMMUNITY SUBCUTANEOUS SYRINGE PUMP CHECKLIST

If more than one syringe pump is in use, complete a separate checklist for each syringe pump
Clearly label each checklist to identify it to its syringe pump, as follows:
Pump supplied by: Syringe pump make and model; Syringe pump serial number; Date of last service (if known).
Date:
Time changed:
Time checked:
Site of needle (state where):
CME T34 SYRINGE PUMPS / Volume infused (VI) on syringe driver mL/hour
volume to be infused (VTBI) (mL):
Battery life remaining (should be >40% to commence):
Slow / fast / on time?
Syringe line & contents clear? (YES / NO)
Needle site condition satisfactory? (YES / NO )
Label corresponds to authorisation chart?
(YES / NO )
Line & connection checked
((YES / NO )
Any action required?
(YES / NO )Record in patient’s notes
Lock box (YES / NO)
Sign & print:
Surname: / Forename:
Date of Birth: / NHS No:
STJH No: / Origin of chart: