DOAC Formulary Review Service - Meeting Request & Scope of Service
Practice Name
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PCN Name
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Practice Code
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Admin/IT lead for system access
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Name
Email
Practice Manager
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Name
Email
Clinical Lead for project and approval of pharmacist interventions:
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Name
Email
GP System
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SYSTM ONE
EMIS
List Size
Scope of Service
Practice approves the service to be conducted remotely with the required data security assurance
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Yes
No
Clinical Lead to assess recommendations & approve intervention within 10 working days or consider the Pre-Authorisation section below
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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
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Yes
No
Pharmacist to implement approved interventions, update consultation notes and templates
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Yes
No
Pre-Authorisation
GP approval to pre-authorise DOAC formulary change in accordance with clinical parameters and following a patient tele-consultation.
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Rows
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
Meeting Request
Please add your preferred Date and Time for a virtual meeting, or alternatively the MMS Admin team will follow up to arrange.
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
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Name
Email
Signature
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On behalf of (Practice name)
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Please verify your submission
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Submit
May 2025
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