Tayside Community Pharmacy Palliative Care Network Contact Recording Form Name of Pharmacy: _______________________________________________ Address: ________________________________________________________ OR Pharmacy Pharmacist’s name:________________________________________________ Medication name, Priority Who initiated Activity Time taken Day/Date/Time strength and request formulation e.g. Mon 21 July at 4.45 1. Urgent (5 10 1. Patient 1. Supply 1. 0 10 mins – – pm mins) 2. Carer 2. Advice 2. 10 30 mins – 2. 3. Health care 3. Choice of therapy 3. 30 mins 1 – 3. Within 24 hours professional 4. Referral hour 4. Over 24 4. (please 5. Other (please 4. Over 1 hour 5. Other (please specify) specify) 5. specify) 1. 2. 3. 4. 5. 6. This form (detailing activity in September 2016) and an anonymised patient story should be submitted by 5th October 2016 to Diane Robertson, Community Pharmacy Development Manager, East Day Home, Kings Cross, Clepington Road, Dundee or emailed to Payment Claim Form Appendix 2 Community Pharmacists Palliative Care Network – (Please complete this form by 7th November 2016 and return it to:- Robertson, Community Pharmacy Development,
Tayside Community Pharmacy Palliative Care Network Contact Recording Form Name of Pharmacy: _______________________________________________ Address: ________________________________________________________ OR Pharmacy Pharmacist’s name:________________________________________________ Day/Date/Time Medication name, strength and formulation Priority Who initiated request Activity Time taken e.g. Mon 21 July at 4.45 pm 1. Urgent (5 – 10 mins) 2. 3. Within 24 hours 4. Over 24 5. Other (please specify) 1. Patient 2. Carer 3. Health care professional 4. (please specify) 1. Supply 2. Advice 3. Choice of therapy 4. Referral 5. Other (please specify) 1. 0 – 10 mins 2. 10 – 30 mins 3. 30 mins – 1 hour 4. Over 1 hour 5. 1. 2. 3. 4. 5. 6. This form (detailing activity in September 2016) and an anonymised patient story should be submitted by 5th October 2016 to Diane Robertson, Community Pharmacy Development Manager, East Day Home, Kings Cross, Clepington Road, Dundee or emailed to Payment Claim Form Appendix 2 Community Pharmacists – Palliative Care Network (Please complete this form by 7th November 2016 and return it to:- Robertson, Community Pharmacy Development,
NHS_Tayside_Palliative_Care_Service_Specification_2016-17.docx