Practice Details
Practice Name
*
PCN Name
*
Practice Code/ODS
*
Pre Audit Checklist
Admin/IT lead for system access
*
Name
NHS Email
Practice Manager
Name
NHS Email
Clinical Lead for project and approval of pharmacist interventions:
*
Name
NHS Email
Clinical Review
Practice approves the service to be conducted remotely with the required data security assurance
*
Yes
No
Clinical Lead to assess recommendations & approve intervention within 10 working days or consider the Pre-Authorisation section below
*
Yes
No
Practice agrees that any overdue monitoring (e.g. blood tests) will be completed within 28 days to allow the pharmacist to implement changes in a timely manner
*
Yes
No
Pharmacist to implement approved interventions, update consultation notes and templates
*
Yes
No
Pre-Authorisation
GP approval to pre-authorise DOAC formulary change in accordance with clinical parameters and following a patient tele-consultation.
*
Authorisation (Y/N)
Change high cost DOAC to appropriate low cost generic alternative
Yes
No
Optimise DOAC strength in line with clinical parameters (e.g. CrCl and Weight)
Yes
No
Please add any further comments in relation to the scope of service or Pharmacist activity in relation to optimising DOAC therapy in NVAF at your Practice:
Service authorised by
*
First Name
Last Name
On behalf of (Practice name)
*
Signature
Please verify your submission
*
Submit
*Remote working will only be conducted after sharing a Data Processing Agreement
Should be Empty: