DOAC Scoping & Pre-Authorisation Form

Practice Details
Practice Name*
PCN Name*
Practice Code/ODS*
List size*
GP Clinical System*

EMISSystmOne
Pre Audit Checklist
Admin/IT lead for system access*

NameNHS Email
Practice Manager for project

NameNHS Email
Clinical Lead for project and approval of pharmacist interventions:*

NameNHS Email
Practice wishes to arrange a virtual meeting to discuss project*

YesNo
Clinical Review
Practice approves the service to be conducted remotely with the required data security assurance*

YesNo
Clinical Lead to assess recommendations & approve intervention within 14 days and/or consider Pre-Authorisation section below*

YesNo
Practice agrees that any overdue monitoring (e.g. blood tests) will be completed within 14 days to allow pharmacist to implement changes in a timely manner*

YesNo
Pharmacist to implement approved interventions following patient telephone consultation and update consultation notes and templates*

YesNo
Please add any further comments in relation to the scope of service or Pharmacist activity in relation to optimising anticoagulant therapy in NVAF at your Practice:
Pre-Authorisation

GP approval to pre-authorise DOAC therapy optimisation in accordance with clinical parameters and following a patient tele-consultation. *

Rows	Authorisation (Y/N)
Optimise DOAC strength in line with clinical parameters (e.g. CrCl and Weight)
Review high risk non-anticoagulated patients suitable for a DOAC recommendation

Please note, details of Patients screened and reviewed as part of this service will be shared with the surgery.
Service authorised by*

First NameLast Name
On behalf of (Practice name)*
Signature

Clear
Please verify your submission*
*Remote working will only be conducted after sharing a Data Processing Agreement

This service has been financially supported by Daiichi Sankyo UK Ltd

DON/22/0006 Feb 2022
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Practice Details