Forms

• FP10 Order Form (Appendix 2)
• A copy of the reconciliation log (Appendix 3) will be pre-populated with serial numbers and issued by the FP10 team with new FP10 pads supplies to the named prescriber / team.
• Home Visit Audit Trail Log (Continuation Sheet of Appendix 3)
• FP10 Environmental Risk Assessment (Appendix 5) - expected April 2025
• FP10 Collection Log (Appendix 7: Annex 1) - expected April 2025
• FP10 Record of Destruction NB - only the FP10 team may destroy unwanted / spoilt / void FP10 prescriptions

The following forms can be found in the MMP04 Covert and Overt Administration of Medicines in Food / Drink (Inpatients) procedure

• Covert Medication Flow Chart
• Covert Medication Care Pathway (Initial) Form
• Covert Medication - Medication Review
• Covert Medication Care Pathway (Review) Form

NB - Electronic versions of these forms are available on RiO under Case Record Menu > Medications > Covert Medication > Covert Medication Care Pathway (Initial)

Electonic versions must also be used where available

GASS Form

Drug Approval Form

Drug Approval Process

The following form can be found in the MMP07 Medicine Reconciliation (Inpatients) procedure:

Medicine Reconciliation Form

The following forms can be found in the MMP08 Administration of Medicines procedure. These are to be used for the self-administration of specified medicines only.

They are not to be used for patients under the Self-Administration of Medicines (SAM) Scheme - see MMP05 Self-Administration of Medicines (SAM) Scheme procedure for these forms.

SELF-ADMINISTRATION OF SPECIFIED MEDICATION -

• PATIENT CLINICAL ASSESSMENT AND CONSENT FORM
• Spot Check Form

Temperature Monitoring Form

Missing, Lost & Stolen NHS Prescription(s) Notification Form & Flow Chart - guidance and form to be followed in the instance of a missing, lost or stolen NHS prescription

Record of Delivery (single patient use form) - to be used when delivering medication / FP10s directly to a patient (i.e. not to a Trust site) or a community pharmacy to provide an accurate audit trail of receipt of the medication / FP10. This should be uploaded to the patient's electronic record.

View Outpatient Depot Prescription 

This is a printable PDF version only

The modifiable template can be found on the G: drive at the location below:

G:\11. Medical\11.4 Medicines Operational\11.4.15 Community OP depot prescription

All MMT staff working across Halton, Warrington, St.Helens & Knowsley have access to this folder.

If you require access to this folder, please request this through the IT Self Service Portal.

Discharge Medicines Service Poster

Wavertree Bungalow POD Information