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Non-formulary request form sample MPFT (seeks outcome feedback)

Up to MMHCPN Members Discussion Forum
March 06. 2020
Rachel Walsh

This non-formulary request form was re-designed Dec 2019 to attempt to capture more comprehensive outcome data when agreement is reached that patients may be prescribed non-formulary items such as Lurasidone, Cariprazine.

This can be fed back to Medicines Optimisation Committee over time and will potentially provide feedback on utility or when a particular agent trends for use in a certain sub-set of patients

Procedure for prescribers wishing to prescribe non-formulary:

  • Prescriber completes Individual Patient Request (IPR) form (no patient name, just NHS #) - space to supply any evidence
  • Prescriber requests pharmacist input/comment to form if pharmacist assigned to team i.e. not all community mental health prescribers will have access to Trust pharmacist. If no pharmacist, prescriber sends direct to Deputy Director Pharmacy
  • Form sent to Deputy Director of Pharmacy who assesses  - generally speaking meds are agreed
  • Signed form returned to prescriber (& pharmacist if one involved), uploaded to patient's electronic notes and stored on pharmacy secure drive for governance information. Pharmacist sends a reminder regarding need to retain prescribing within Trust if no Shared Care Agreement.
  • At next monthly Medicines Optimisation Meeting (i.e. DTC) all IPR forms are shared for information
  • Formulary pharmacist (in governance team) requests feedback at the intervals indicated on form. For in-patients it is better if there is liaison between ward pharmacist and formulary pharmacist as to whether patient has been discharged or not at the 1 month review (inpatient consultant always discharges to a different community consultant)
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