Scope of Intention to Prescribe PLEASE COMPLETE THIS DOCUMENT ELECTRONICALLY (TYPED) & IN DETAIL

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1 Scope of Intention to Prescribe PLEASE COMPLETE THIS DOCUMENT ELECTRONICALLY (TYPED) & IN DETAIL Full Name: Job Title: Work Base: Address: Contact No: Line Manager Name: Date written: Revalidation date [yearly] State which group(s) of patients / clients you will be prescribing for e.g. children, adults with diabetes State your speciality(s) e.g. COPD, type 2 diabetes, wound care, paediatrics.

2 Detail the disease areas you will prescribe in Detail the type (including BNF section) of medicines you will prescribe Detail the type (including BNF section) of medicines you will not prescribe Detail any medicines that you will prescribe as part of a clinical management plan (CMP) Detail your evidence to prescribe competently in this area (i.e. training undertaken and work experience done with dates / periods of time): Detail your recent CPD which supports your prescribing in this area (include dates) State the guidelines or protocols you work to Asthma (Step 1-4 not Step 5) in adults and children over 5 years Selective beta 2 agonists (inhaled only) 3.2 Corticosteroids (inhaled only) Leukotriene receptor antagonists Theophylline Oxygen None Prescribing portfolio Mar 09 based on asthma patients 5 years running asthma clinics in hospital Attended Non Medical Prescribers update on asthma Shadowing respiratory nurse specialist and asthma team Reading journal articles as published e.g. BMJ & receive updates British Guideline on the Management of Asthma. BTS/ SIGN 2012

3

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5 How will you audit your prescribing: Governance of your prescribing How will you monitor the patient experience of patients attending your clinic / service: Describe the on-going supervision / mentorship that you receive within your clinical area for your prescribing: Including peer review & access to a designated mentor. As part of your appraisal, you are asked to share three clinical reflections of scenarios where you have or have not prescribed. This corresponds to the core components of the Single Competency Framework [NICE 2012] urces/single_comp_framework.pdf Please provide a sentence for each scenario discussed.

6 Identify your CPD needs relating to your area(s) of competence and clinical practice, including prescribing Area of CPD identified Helpful hint : be specific and realistic in your area State how you will meet your identified need e.g. through training, shadowing, supervised practice, peer discussions Date to meet this CPD need by Helpful hint: be realistic

7 Declaration Please state if the following statements are true or false by inserting T for True or F for False in the column provided 1. I will not prescribe for myself or my family 2. I will not issue prescriptions unless the drug(s) are within my scope of practice, and I have undertaken a review of the patient s need for a prescription. 3. As a SSOTP employee, the partnership trust will support you in your prescribing activities under vicarious liability but it is recommended that you also have appropriate indemnity arrangements such as membership of professional bodies such as that provided by organisations such as the RCN, Unison etc 4. I keep myself up to date in practice. I have access to and receive alerts. 5. I have attended the mandatory two yearly medico-legal issues update session facilitated by SSOTP. 6. I have discussed my scope of practice with my line manager 7. I have read the non-medical prescribing policy 8. I have undertaken peer review of my prescribing practice 9. I understand if I do not use my prescribing skills or if I do not comply with the trusts protocols then the trust will suspend my right to prescribe & I will surrender my prescription pads. 10. I confirm my appraisal included a review of my prescribing performance I declare that this is my current Scope Of Practice Agreement and that I will update it annually or sooner if my area of competence and clinical practice changes. I agree to keep up-to-date with current guidance and evidence-base. Your signature: Line Manager signature: Seen & Approved by: SSOTP Non-Medical Prescribing Lead: Date: Date: Date: Acknowledgement to NHS Southwark

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