This is an HTML version of an attachment to the Official Information request 'PIC line policy'.

R1123HWF
Peripheral Inserted Central 
code  Catheter (PICC) referral form  Sherlock PICC service mobile number: 021 926 272
Bar
For referrals: Fax number 94456
Patient information
Laboratory results
Pregnant                     Yes       No INR : 
Date:
APTT:
Date:
dd/mm/yy
dd/mm/yy
Interpreter needed      Yes        No Platelets:
Date:
Prothrombin:
Date:
dd/mm/yy
dd/mm/yy
Creatinine:
Date:
Hb:
Date:
dd/mm/yy
dd/mm/yy
Patient referral criteria:
•  ≥ 16 years of age               Yes          No          •  Artificial and/or pacemaker wire present         Yes        No  
•  Alert and orientated            Yes          No          •  Atrial fibrillation (AF) or Paroxysmal AF         Yes        No  
       
 
 
 
 
 
•  Able to lie still in enclosed spaces                Yes         No
•  Preprocedure bloods done         Yes        No              
•  Platelets ≥20 
 
        Yes        No
•  Coagulation screen INR≤1.5        Yes        No  -  Inpatient within last 3 days 
 
  Yes          No  
 
 
 
 
                                 -  Outpatient on any anticoagulant 
 
 
 
 
 
 
            therapy within last week 
 
    Yes        No
 
 
 
 
            
             If yes, name of medication:
•  Clotting screen done within 1 week prior to PICC insertion           Yes    No   
PICC triage score below: 
 Score 5
Score 3
Score 1
IV Chemotherapy – Date treatment begins 
0 - 2 days
3 - 7 days
1 or more weeks     =
Or Community IV antibiotic therapy – treatment begins
0 - 2 days
3 - 7 days
1 or more weeks     =
Or IV nutrition
Yes
No
    =
Has nutrition support team accepted patient?                 
Yes
 No
   
Difficult venous access
Yes
No
    =
                                Total score
    =          /10
Allergies / Alerts:
Infection status:        MRSA             ESBL             VRE
Other:
Relevant clinical history (including any cardiac conditions, previous central venous access devices) and treatment plan.
Referring doctor MUST sign Lignocaine 1% prescription to provide local anaesthesia.
Date:    
 
Time:    
   
      Lignocaine 1% subcut 0.5 – 3 ml for PICC insertion
dd/mm/yy
24 hour
Prescribers name (Print):  
 
 
       
 
Prescribers signature:   
 
Contact details:
Faxed or scanned to: (94456)
To be filed in Clinical Record in Correspondence section
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07/16JB