IP LogBook
T&H FP10 Audit and Logbook
Date
*
-
Month
-
Day
Year
Date
What are you trying to do with your FP10
*
Please Select
Prescribe Meds
Dispose of an FP10
Order FP10's
Accept a delivery of FP10's
Report an indcident
Back
Next
FP10 Disposal
Name of person disposing
First Name
Last Name
FP10 Number?
*
Reason for disposal?
*
Please Select
Writing error
Not eligible
Mistake with Px details
Mistake with drug
No longer required
Any other Comments?
*
FP10 destroyed?
*
Yes
No
Please give further dteails
*
Back
Next
FP10 Ordering
Name of person ordering FP10's
*
First Name
Last Name
Order method
Email
Phone
Via PES
How many pads ordered
*
Order Number?
Expected delivery date?
(If not received within 6 days of expected date report incident)
Back
Next
Delivery of FP10's
Any discrepancies MUST be escalated to: 0800 028 4060 or online at: https://cfa.nhs.uk/reportfraud
Name of person taking delivery
First Name
Last Name
Name of assistant taking delivery
First Name
Last Name
Is the packaging intact?
Yes
No
How many FP10 Pads received?
Serial No's checked and match documentation?
Yes
No
Serial number
Serial number
Serial number
Serial number
Serial number
Serial number
Please document any discrpencies?
Report incident?
Yes
No
Secure Storage
FP10's Stored by?
First Name
Last Name
Securely stored?
First/Last FP10 number on pad
First/Last FP10 number on pad
First/Last FP10 number on pad
First/Last FP10 number on pad
First/Last FP10 number on pad
First/Last FP10 number on pad
Name of prescriber taking responsibility
First Name
Last Name
GOC Number
Date taken posession
-
Month
-
Day
Year
Date
Back
Next
Incident Reporting
Type of Incident
*
Please Select
Loss by Patient
Lost blank forms
Stolen Forms
Delivery Issues
Practice Address
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reporter Name
*
First Name
Last Name
Phone number
Email
*
example@example.com
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
*
Type of Prescription on stationary
*
Quantity
*
Serial Number/Numbers
*
Prescriber details
*
Counter fraud notified?
*
Yes
No
Counter fraud details
*
Police notified?
*
Yes
No
Police details
*
Back
Next
Prescribe Meds
Patient Details
Name of Prescriber
First Name
Last Name
Is this patient from?
*
T&H Optometrists
Blackpool Victoria Hospital
XeyeX ID / Hospital Number
*
FP10 Number?
*
Diagnosis
*
Known Allergies (If yes detail below)
Yes
No
Other Information
Drug Prescribed?
*
Dose?
*
Route
*
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
*
Please Select
OD
BD
TDS
QDS
5x
6x
2 Hourly
Hourly
Tapering Dose
PRN
Tapering Dose
*
Rows
OD
BD
TDS
QDS
5x
6x
Hourly
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Amount prescribed?
*
Please Select
One week
Two weeks
One month
Two months
Three months
Ongoing
Onward referral?
*
Yes
No
Would you like to add more meds?
*
Yes
No
Drug Prescribed?
*
Dose?
*
Route
*
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
*
Please Select
OD
BD
TDS
QDS
5x
6x
2 Hourly
Hourly
Tapering Dose
PRN
Tapering Dose
*
Rows
OD
BD
TDS
QDS
5x
6x
Hourly
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Amount prescribed?
*
Please Select
One week
Two weeks
One month
Two months
Three months
Ongoing
Would you like to add more meds?
*
Yes
No
Drug Prescribed?
*
Dose?
*
Route
*
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
*
Please Select
OD
BD
TDS
QDS
5x
6x
2 Hourly
Hourly
Tapering Dose
PRN
Tapering Dose
*
Rows
OD
BD
TDS
QDS
5x
6x
Hourly
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Amount prescribed?
*
Please Select
One week
Two weeks
One month
Two months
Three months
Ongoing
Would you like to add more meds?
*
Yes
No
Drug Prescribed?
*
Dose?
*
Route
*
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
*
Please Select
OD
BD
TDS
QDS
5x
6x
2 Hourly
Hourly
Tapering Dose
PRN
Tapering Dose
*
Rows
OD
BD
TDS
QDS
5x
6x
Hourly
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Amount prescribed?
*
Please Select
One week
Two weeks
One month
Two months
Three months
Ongoing
Would you like to add more meds?
*
Yes
No
Drug Prescribed?
*
Dose?
*
Route
*
Please Select
Right Eye
Left Eye
Both Eyes
Oral
Frequency?
*
Please Select
OD
BD
TDS
QDS
5x
6x
2 Hourly
Hourly
Tapering Dose
PRN
Tapering Dose
*
Rows
OD
BD
TDS
QDS
5x
6x
Hourly
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Amount prescribed?
*
Please Select
One week
Two weeks
One month
Two months
Three months
Ongoing
Back
Next
Thank you Please now submit
Submit
Should be Empty: