Updated 4/8/10 Version 2
Summary record of consultations
Month: ______Pharmacystamp/ address:
Pharmacist Name: ______
Date / Staff Initials / Postcode / Age / Reason (1) / Test (2) / Supply (3) / Dose (4) / Referral (5) / Prior (6) / Chlamydia test issued / Condom Pack Supplied(tick) / Time
(7) / Source
(8) / Ethnicity (9)
Total number of consultations: / Total number of referrals:
Total number of Tablets: / Total time taken (minutes):
All Paperwork to be returned to: Medicines Management, Bevan House, 1 Esh Plaza, Sir Bobby Robson Way, Great Park, Gosforth, Newcastle Upon Tyne, NE13 9BA
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust
Updated 4/8/10 Version 2
Key:
(1) Reason for patient’s concern:
U = unprotected, C = contraceptive failure, M = missed pill, O = other
(2) Was a pregnancy test given:
P = pre-supply, A = post-supply, B = both
(3) Was EHC supplied:
L = Levonelle, E = EllaOne, N = no
(4) What dose was supplied:
S = standard dose, A = additional dose (enzyme inducer), R = repeat dose after vomiting
(5) Was the client referred:
N = no, G = GP practice, H = specialist service, P = another pharmacy, S = school health adviser
(6) Is the patient known to have requested EHC in the previous three months:
Y = yes, 0 = unknown, N = no
(7) Time taken: enter the time, in minutes taken to complete the consultation and associated records
(8) Source: where the patient heard about the scheme:
M = Media (Newspaper, Radio, Flyer)
P = Poster
R = Recommendation from a friend/relative
H = Recommendation from a health professional (GP, Nurse, Health Visitor, Sexual Health Clinic)
O = Other
(9) Ethnicity Codes:
White / Black or Black BritishA / British / M / Caribbean
B / Irish / N / African
C / Any other white background / P / Any other Black background
Mixed / Other ethnic categories
D / White and Black Caribbean / R / Chinese
E / White and Black African / S / Ant other ethnic category
F / White and Asian / Not Stated
G / Any other mixed background / Z / Not Stated
Asian or Asian British
H / Indian
J / Pakistani
K / Bangladeshi
L / Any other Asian background
Form to be returned with the monthly Invoice to:
Medicines Management, NHS North of Tyne, Bevan House, 1 Esh Plaza, Sir Bobby Robson Way, Great Park, Newcastle upon Tyne, NE13 9BA.
Form to be returned no later than the 5th of the month.
Record of consultation for Plan B (EHC)
Pharmacy stampClient’s name: …………………………………………………..
Date of consultation: …………………………………………..
Age / DOB: …………………… Ref no…………………………
Post code: ………………… Ethnicity…………………………
NHS Number: ………………………
Patient’s history
Date of first day of last menstrual cycle: …………………….. therefore day ………of cycle
Has the patient had Levonelle® or EllaOne® since last period? ………..
Reason for request: Unprotected……. Failure…… Missed pill…… Other…….
Criteria for inclusion / Yes / No / N/AIs the patient beyond the 3rd day of a spontaneous menstrual cycle?
Has the patient missed her contraceptive pill?
Advice given if missed contraceptive pill?
Patient has received EHC but has vomited within two / three hours (provided UPSI still within 120 hour period)
All options for emergency contraception including copper IUD discussed?
Client prefers hormonal method
Criteria for exclusion (referral) / Yes / No / Notes
Did UPSI occur between 72 and 120 hours ago? / If ‘yes’ discusscopper IUD as first choice butcan dispense EllaOne or Levonelle 1500 if within 120 hours
Has the patient used Levonelle or EllaOne within this cycle? / If ‘yes’ – discuss more effective contraceptive methods but further Levonelle 1500can be given
Is the client pregnant or likely to be pregnant? / If ‘yes’ pregnancy test should be performed. If refused – refer
If the client is not using hormonal contraception was her last period more than 4 weeks ago? / If ‘yes’ perform a pregnancy test or refer. Levonelle 1500 or EllaOne may be given if you are reasonably sure she is not pregnant.
If the client is not using hormonal contraception was her period abnormal, different length or flow? / If ‘yes’ perform a pregnancy test or refer. Levonelle 1500 or EllaOne may be given if you are reasonably sure she is not pregnant.
Does the client have breast cancer? / If ‘yes’ – refer
Does the client have severe liver disease? / If ‘yes’ – refer
Does the client have porphyria? / If ‘yes’ – refer
If under 16 years of age, is the client deemed competent? / If ‘no’ – refer
Additional information: does the patient require an increased dose (two tablets of Levonelle 1500) taken as a single dose e.g. malabsorption disease, concurrent liver enzyme inducer? …...... Reason: ………………………………….
Counselling / Yes / NoMode of action discussed
Failure rate discussed
Side effects discussed
Possible effects on foetus discussed
Dose taken on premises
Time of second dose agreed (if increased dose required)
Follow-up discussed
Future contraception discussed
Chlamydia screening discussed
Other relevant information:
Where the patient heard about the scheme: …………………………………………………..
Action taken:If supply made: Batch number: Expiry date:
Referral to:
Advice given:
The above information is correct to the best of my knowledge. I have been counselled on the use of emergency contraception and understand the advice given to me by the pharmacist.
Client’s signature:______Date:______
The action specified was based on the information provided to me by the client, which, to the best of my knowledge, is correct.
Pharmacist’s signature:______Date:______
Time taken to complete consultation ……………. minutes.
Patient identifiable information – private and confidential
Referral for Contraceptive Support
Patient details:
First Name: ……………………………… Last Name: ………………….
DOB/AGE: …………………….NHS Number: ………………..
Address: ………………………………………………………………………….
…………………………………………………………………………………………….
GP: …………………………………1st day of LMP: ……………………..
Pharmacy contact date:………………… EHC provided: Y / N
I have agreed with the patient that their preferred method of contact is: (Please circle preferred method)
Telephone call: Land line / mobilePostText message
Telephone number: …………………………….….
Address: ……………………………………………………………………………
……………………………………………………………………………………………
Reason for referral…………………………………………………………………
Referrer (Pharmacy Details).
Name (Please Print) …. ………………………………….
Registration Number ……………………………………..
Pharmacy Address: ……………………………………………………………………….
…………………………………………………………………………………………………….
I have agreed with the patient that I will pass their details onto the sexual health service who will contact them to arrange an appointment.
Pharmacist
Signature ………………………………………………………………Date:…………
Please return by Fax to chosen sexual health clinic for follow up appointment:
NORTHUMBERLAND NORTH TYNESIDE NEWCASTLE
Carlton Street Clinic 1 – 1 Centre New Croft Centre
Blyth Brenkley Avenue Market Street
Northumberland Shiremoor Newcastle
NE24 2DT NE27 0PK NE1 6ND
Tel: 01670 543130 Tel: 0191 2970441 Tel: 0191 229 2999
FAX: 01670 543132 FAX: 0191 2979857 FAX:0191 229 2979
Assessing competence for patients according to Fraser guidelines
A young person’s competence to understand their treatment must be assessed. The assessment must be fully documented and should include an assessment of the patient’s maturity. The discussion with the patient should explore the following issues at each consultation:
Assessment of competence / Yes / NoUnderstanding of advice given
Encouraged to involve parents
The effect on the physical or mental health of the young person if advice / treatment is withheld
Action is in the best interest of the young person
Pharmacist’s name ______
(Block capitals)
Pharmacist’s signature______Date______
Client’s name ______
(Block capitals)
Client’s signature______Date ______
Working on behalf of Newcastle and North Tyneside Primary Care Trusts and Northumberland Care Trust