IV Therapy | ECCH

Community IV Referral Form to ECCH

ECCH Integrated Care Co-ordination Centre (ICCC) 01493 809977

Patient MUST already have a PICC line, Mid line or Cannula

Patients to attend ECCH site with Medication Prescription chart, discharge summary and a supply of the medicines

Patient Details

NHS Number *

Surname *

Forename *

Address *

GP *

Phone No *

Mobile No *

Referring Consultant

Consultants Name *

Referrers Name *

Referrers Contact Number *

Referrers Designation *

Clinical Diagnosis *

Organism/ Sensitivity & Date of result *

Previous medical history *

Has patient got a PICC line, Mid line or cannula ? *

PICC MID Cannula

Date PICC line/ Mid line/ Cannula inserted *

SecurAcath/ Statlock in place *

Yes No

Discussed with Microbiologist *

Yes No

Recommendations *

Allergies *

Proposed IV Therapy (1)

Drug & Dose *

Date Of First Dose *

Infusion or Bolus *

Frequency *

Duration *

Planned Last Dose *

Review date & Bloods *

Proposed IV Therapy (2)

Drug & Dose *

Date Of First Dose *

Infusion or Bolus *

Frequency *

Duration *

Planned Last Dose *

Review date & Bloods *

Proposed IV Therapy (3)

Drug & Dose *

Date Of First Dose *

Infusion or Bolus *

Frequency *

Duration *

Planned Last Dose *

Review date & Bloods *