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UNCONTROLLED WHEN PRINTED Review Date: August 2020 Identifier: NHSG/Inst/WPC/MGPG899 - i - Instructions for Using the In-Patient Warfarin Prescription Chart in NHS Grampian – Version 2

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Title: Instructions for using the In-Patient Warfarin Prescription

Chart in NHS Grampian

Unique Identifier: NHSG/Inst/WPC/MGPG899 Replaces: NHSG/Inst/WPC/MGPG618, Version 1.1 Lead Author/Coordinator: Principal Pharmacist (Clinical), Aberdeen Royal Infirmary Subject (as per document registration categories):

Prescribing and prescription

Key word(s): Warfarin, instructions, prescribing, administration,

medicines, in-patient, prescription, chart Policy, Protocol, Procedure or Process Document:

Guidance

Document application: Whole of NHS Grampian Purpose/description: To promote the safe use of the In-Patient Warfarin

Prescription Chart. Group/Individual responsible for this document:

Records Standards Group

Policy statement: It is the responsibility of individual healthcare professionals

and their line managers to ensure that they work with the terms laid down in this guidance and to ensure that staff are working to the most up to date guidance. By doing so, the quality of the services offered will be maintained, and the chances of staff making erroneous decisions which may affect patient, staff or visitor safety and comfort will be reduced. Supervisory staff at all levels must ensure that healthcare professionals using this guidance act within their own level of competence.

UNCONTROLLED WHEN PRINTED Review Date: August 2020 Identifier: NHSG/Inst/WPC/MGPG899 - ii - Instructions for Using the In-Patient Warfarin Prescription Chart in NHS Grampian – Version 2

Responsibilities for ensuring registration of this document on the NHS Grampian Information/ Document Silo:

Pharmacist, Pharmacy and Medicines Directorate

Lead Author/Coordinator: Principal Pharmacist (Clinical), Aberdeen Royal Infirmary Physical location of the original of this document:

Pharmacy Office, Aberdeen Royal Infirmary

Job title of creator of this document:

Principal Pharmacist (Clinical), Aberdeen Royal Infirmary

Job/group title of those who have control over this document:

Records Standards Group

Responsibilities for disseminating document as per distribution list: Lead Author/Co-ordinator Principal Pharmacist (Clinical), Aberdeen Royal Infirmary Responsibilities for implementation: Organisational: Acute Sector Operational Management Team and Acute

Sector General Manager Hospital/Interface services: Assistant General Managers and Group Clinical Directors Operational Management Unit:

Unit Operational Managers

Departmental: Clinical Leads Area: Line Managers

Review: This policy will be reviewed in two years or sooner if current

treatment recommendations change Responsibilities for review of this document: Lead Author/Coordinator: Principal Pharmacist (Clinical), Aberdeen Royal Infirmary Review date: Review 3 yearly. Any significant changes in evidence will

result in earlier alteration.

Revision History:

Revision Date Previous Revision Date

Summary of Changes (Descriptive summary of the changes made)

Changes Marked* (Identify page numbers and section heading )

August 2017 November 2013 2 yearly update. August 2017 November 2013 2 grammatical errors . Introduction (page 1) August 2017 November 2013 Section headings

added. Throughout document

UNCONTROLLED WHEN PRINTED Review Date: August 2020 Identifier: NHSG/Inst/WPC/MGPG899 - iii - Instructions for Using the In-Patient Warfarin Prescription Chart in NHS Grampian – Version 2

August 2017 November 2013 Minor amendments to prescription examples in line with updated “Instructions for NHS Grampian Staff on the Prescribing and Administration of Medicines Using the NHS Grampian Prescription and Administration Record”.

All examples updated

UNCONTROLLED WHEN PRINTED Review Date: August 2020 Identifier: NHSG/Inst/WPC/MGPG899 - 1 - Instructions for Using the In-Patient Warfarin Prescription Chart in NHS Grampian – Version 2

Instructions For Using The In-Patient Warfarin Prescription Chart In NHS Grampian Contents Page No: 1. Introduction ........................................................................................................ 2

2. Prescribing Guidance ......................................................................................... 2

2.1. Prescription and Administration Record (PAR) .................................................. 2

2.2. In-Patient Warfarin Prescription Chart ................................................................ 3

2.3. Discontinuing Warfarin Therapy ......................................................................... 5

3. Completing Discharge Checklist ........................................................................ 6

3.1. Warfarin Therapy Started Prior to Admission (Example 7) ................................. 6

3.2. Warfarin Therapy Started During Admission (Example 8) .................................. 7

Appendix A: In-Patient Warfarin Prescription Chart .................................................... 8

Appendix B: In-Patient Warfarin Prescription Chart (Long Stay) .............................. 10


Instructions for Using the In-Patient Warfarin Prescription Chart in

NHS Grampian 1. Introduction This chart is intended to be used only for the prescription of warfarin to in-patients. This prescription chart requires that an entry be made detailing the warfarin dose for each day. This prescription chart should always be used in conjunction with a Prescription and Administration Record (PAR), i.e. main kardex. As with all prescription charts in NHS Grampian, this chart should be completed legibly in black ink and in BLOCK LETTERS. Note: There are 2 versions of the warfarin in-patient prescription chart, the standard version (Appendix A) and the long-stay version (Appendix B). Both charts should be completed using the following instructions. 2. Prescribing Guidance 2.1. Prescription and Administration Record (PAR) 1) Complete all necessary biographical details on the Prescription and

Administration Record (PAR) (if not already done) according to NHS Grampian guidelines. Ensure the ‘Known Medicine Allergies/Sensitivities’ box has been completed on the PAR and that there is no record that the patient has sensitivity to the drug which is to be prescribed.

2) In the ‘Other Medicine Charts or Treatment Plans in Use’ section, ensure that the box is ticked indicating that the In-Patient Warfarin Prescription Chart (‘Oral anticoagulation prescription sheet’) is in use (Example 1).

Example 1: Other Medicine Charts or Treatment Plans in Use Entry


3) Prescribe warfarin in the regular therapy section of the PAR (Example 2).

Example 2: Regular Therapy Entry 2.2. In-Patient Warfarin Prescription Chart (See Appendix A – standard version, Appendix B – long stay version and Examples 3 and 4 below) 1) Complete the biographical details at the top of the ‘In-Patient Warfarin

Prescription Chart’

• Patient’s name: Full name in BLOCK LETTERS. • Date of birth: Written as, e.g. 13.01.89. • CHI number: Patient’s community health index number in full,

e.g.1301890000. • A printed patient label may be used for the above. • Ward: Ward name should be written in full. • Hospital: Abbreviations can be used, e.g. ARI. • Consultant: Surname should be written in full. • Allergies: Complete the allergy box/boxes – if no allergies /sensitivities

write ‘NKDA’ in box 1. • Date of admission. • Prescription number – record chronologically.

2) Indication – select the indication for the patient being prescribed warfarin (tick

box); if the indication is not listed state under ‘other’. 3) Warfarin on admission box – complete if patient was taking warfarin on

admission to hospital and complete the dose and intended duration. 4) New warfarin therapy box – if warfarin therapy is new, select one of the

regimes from the reverse of the chart and enter fast or slow, as appropriate into the box. In some specialist areas the senior doctor may specify a regime which is different from the fast or slow initiation schedules, in this case leave the box blank.


5) Concurrent medicines box – if the patient is on any other medicine known to interact with warfarin (see current version of BNF), then please state here and specify likely effect.

6) Warfarin prescribing – please refer to dosing regime selected if new therapy,

otherwise clinical decisions on dosing should be made using the INR results and taking into account the warfarin dose on admission.

7) For each day’s medication prescribed, the prescriber must complete:

• the date • the INR result when checked • the medicine, i.e. warfarin • the dose in mg or ‘withhold’ if no dose to be administered • the time, usually 1800 • a signature/print name.

8) In the ‘Dose’ column, write the required dose to be given at that time. The

smallest dose increments are 500micrograms (doses less than 1mg should be prescribed in ‘micrograms’ – do not abbreviate).

9) When administering the medication the nurse(s) involved should follow NHS

Grampian guidelines for medicines administration and sign the ‘Administered By’ section on the In-Patient Warfarin Prescription Chart.

10) If a dose is not administered, write an explanation in ‘Administered By’ column,

e.g. patient refused dose at 1800.

Example 3: Patient Admitted on Warfarin

Life-long 3mg daily

Amiodarone increases INR

1/9/17 2.4 Warfarin 3mg 1800 A Doctor A. DOCTOR A Nurse 2/9/17 2.6 Warfarin 3mg 1800 A Doctor A. DOCTOR A Nurse


Example 4: New Warfarin

2.3. Discontinuing Warfarin Therapy 1) When warfarin therapy is discontinued, two diagonal lines should be drawn

across the administration record box and the date of discontinuation and prescriber’s signature should be added.

2) The medication must also be discontinued on the Prescription and Administration Record (PAR) (Examples 5 and 6).

Example 5: Discontinuation of Other Medicine Charts or Treatment Plans in Use Entry

Fast

1/9/17 Warfarin 10mg 1800 A Doctor A. DOCTOR A Nurse

2/9/17 1.2 Warfarin 10mg 1800 A Doctor A. DOCTOR A Nurse

3/9/17 1.7 Warfarin 10mg 1800 A Doctor A. DOCTOR A Nurse


Example 6: Discontinuation of Regular Therapy Entry

3) The In-Patient Warfarin Prescription Chart should be filed in section D of the patient’s medical notes.

3. Completing Discharge Checklist The discharge checklist should be completed on or before discharge. Whilst some parts of the checklist can be completed during the admission, the whole section should be reviewed on discharge by the healthcare professional discharging the patient. 3.1. Warfarin Therapy Started Prior to Admission (Example 7) 1) All patients must be given an anticoagulant pack if they haven’t received one

in the past. 2) The recording (yellow) booklet must be completed detailing the doses given

during admission and the INRs recorded. 3) The patient/relative/carer must be aware of the doses to be taken and when

and where the next INR check needs to be done.

Example 7: Warfarin Therapy Started Prior to Admission

N/A

Yes 1/9/17 A Doctor Yes 1/9/17 A Pharmacist

INR check 3/9/17 GP A Nurse

Done previously

Brought book in


3.2. Warfarin Therapy Started During Admission (Example 8) 1) All patients must be given an anticoagulant pack containing information on

warfarin and a recording book and alert card.

2) They should receive full counselling on this new treatment. 3) The recording (yellow) booklet must be completed in full detailing the doses

given since therapy started and the INRs recorded. 4) The patient/relative/carer must be aware of the doses to be taken and when

and where the next INR check needs to be done. 5) The patient’s GP surgery must be contacted to ensure they are aware of a

new patient on warfarin.

Example 8: Warfarin Therapy Started During Admission

Yes 1/9/17 A Pharmacist Yes 3/9/17 A Pharmacist Yes 5/9/17 A Doctor Yes 5/9/17 A Nurse Yes 5/9/17 A Doctor INR check 7/9/17 GP A Nurse


Appendix A: In-Patient Warfarin Prescription Chart


Appendix A (continued): In-Patient Warfarin Prescription Chart


Appendix B: In-Patient Warfarin Prescription Chart (Long Stay)


Appendix B (continued): In-Patient Warfarin Prescription Chart (Long Stay)

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