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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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