Home Intravenous Therapy Team (HITT) Patient Referral Form
Department
Referral Date
Time
Person Referring
Designation
Contact Number/Bleep
Address Label
Consultant
GP/GP Surgery
Condition being treated
Weight
Relevant MC&S
Allergies
Type (please circle)
Cannula 22g
Cannula 24g
PICC
Midline
IV Access Details
Initial Dose(s)
given on ward
Location
Date Inserted
Antibiotic
Dose
Time
Antibiotic
Dose
Time
Antibiotic
Dose
Time
Date and time of
next dose
Antibiotic
Dose
Frequency
Duration
IV Antibiotics to
be administered
Management Plan
after initial IV
treatment
Step Down to Oral
Therapy (provide details)
Review in clinic (provide
details)
Relevant Medical
History &
Additional care
needs
HB
CRP
BP
Blood Results – last 24 hours
CREATINE
WCC
NEUT
UREA
HR
Clinical Observations
SPO2
RESPS
Home Intravenous Therapy Team (Tel. 0161 741 2008 Fax. 0161 741 2057)
PLAT
POTASSIUM
TEMP
Address Label
General Condition & Relevant Information
Mobile
Yes / No
Lives alone independently or with carer
Yes / No
Is patient able to return to hospital if needed
Yes / No
Eating and drinking
Yes / No
Informed consent achieved
Home environment suitable (phone, running
Yes / No
water, electricity, access for nurse, animals etc.)
Yes / No
Additional Information
Completed referral forms to be faxed to the Home IV Therapy Team (Fax: 0161 741 2057). Please also
attach a copy of the patient’s discharge/outpatient prescription.
Referrals will be accepted from Monday to Sunday between 9:00am and 6:30pm
For Office Use Only
Referral Received By
Acceptance Criteria Met?
Date
Yes
No
Referral Accepted?
Comments
Home Intravenous Therapy Team (Tel. 0161 741 2008 Fax. 0161 741 2057)
Time
Yes
No