Parenteral Nutrition for Home Infusion Therapy

This referral form is provided in order to best serve our patients and prescribers. Patients may choose any pharmacy of their choice

Complete patient demographics below or otherwise provide the information requested along with this referral form. Also needed: 1) Patient insurance information (front and back of card) 2) History and physical, chart notes, recent baseline laboratory results and other diagnostic tests needed to support the use of this medication 3) patient’s medication history related to their current diagnosis/problem.

Date Medication Needed:

Ship to:

Patient

Prescriber

Other

Patient first name:

Patient last name:

Date of birth:

height:

Address

Weight history:

Phone number(s):

Allergies/Intolerances:

Treatment Diagnosis/Problem(s)

Diabetes?

Yes

No

Heart Disease?

Yes

No

Expected duration of therapy:

Patient is NPO?

Yes

No

Prescriber name:

Contact person:

Office Address:

Phone number:

Fax number:

NPI number:

It is suggested that you contact the MedRx Clinical Pharmacist to discuss this patient’s treatment plan. The patient should have an existing central venous catheter for this type of infusion.

Parenteral Nutrition per MedRx Clinical Pharmacist, including formula and adjustments, and clinical lab tests.

Follow the Parenteral Nutrition orders from the discharging hospital (continue same formula at home), but the MedRx Clinical Pharmacist may adjust the formula based upon the patient’s clinical response and laboratory results.

I am providing a formula that I want the patient to have. I will order all laboratory tests to monitor this therapy

List any adjunct medications or therapies that will need to be provided by the parenteral route while the patient is on parenteral nutrition:

Health to maintain the intravenous catheter and MedRx to provide supplies needed including NaCl 0.9% flush and Heparin 100units/ml flush per nursing and pharmacy protocol.

The Home Health Nurse will teach the patient/caregiver to manage the therapy, which may include management and flushing the intravenous catheter, administration of the medication, working and trouble-shooting the infusion pump, draw blood for laboratory work and follow skilled nursing procedures for home care patient safety and comfort. If the patient is not homebound, the nurse will teach the patient to manage his/her therapy to the extent possible

I will receive exact prescripition information for this patient based upon the pharmacist’s assessment and my orders for my patient’s clinical needs. I will sign and return those prescriptions as presented, as the prescriber.

Date:

IMPORTANT NOTICE: This form my contain confidential and privileged information and is only intended only for the person named herein. If you are not the named addressee, do not disseminate, distribute or copy this form or any of its contents. Please notify the sender immediately if you have received this document by mistake, then destroy this form.