EMERGENCY MEDICAL KIT ORDER – FORM
REMOTE HEALTH– Section 16: PHARMACY
PRIMARY HEALTH CARE
The Department of Health Emergency Medical Kits (DoH EMK) are only available to persons who have been authorised to
possess a Medical Kit. See Remote Health Atlas Emergency Medical Kits and DoH Medical Kits for detailed information.
EMERGENCY MEDICAL KIT ORDER - FORM
Please type in boxes provided; cells will expand as text is entered.
Licence / Property Name:
Kit Holder:
Property Postal Address:
Phone Number:
Fax Number:
E-Mail Address:
Authorised Kit Holder
Signature:
Authorisation Number:
(attach copy of current authorisation)
Is this order for a: new kit
resupply of existing kit
Date of order:
Send to:
Please forward this form to the Regional Hospital Pharmacy in your region:
Phone
Fax
Alice Springs Hospital
Pharmacy
(08) 8951 7570
(08) 8951 7766
Katherine District Hospital
(08) 8973 9236
(08) 8973 9010
Delivery Instructions:
e-Mail
alicespringspharmacy.dhcs@nt.gov.au
KDHPharmacy.THS@nt.gov.au
(complete relevant section below)
**Allow at least THREE weeks for delivery and collection**
Collect from Alice Springs Hospital Pharmacy
Date of collection:
Collect from Katherine Hospital Pharmacy
Date of collection:
Collect from nearest Health Centre / Barkly Mobile
Name of Health Centre / Barkly Mobile
Date of collection
Send by Australia Post
Mail Plane Days
Date for Dispatch
Note: The Authorised Kit Holder must sign the order form before the order is submitted.
Pharmacy / PHC Communication:
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Page 1
Review Due: September 2018
REMOTE HEALTH– Section 16: PHARMACY
EMERGENCY MEDICAL KIT ORDER – FORM
EMERGENCY MEDICAL KIT ORDER CHECKLIST
Using this Checklist will help to ensure you complete all the necessary
requirements for obtaining your next EMK supplies.
Have you completed all details on page 1 of the EMK Order - Form
Have you attached a copy of your current authorisation
Have you signed the EMK Kit Order – Form (page 1 and page 7)
Have you provided delivery instructions (page 1)
Have you completed the order for medicines and medical sundries (pages 7
– 10)
Have you attached a copy of the Register for Morphine (page 3)
Have you attached the Record of Use of Medicines Form (page 4)
When relevant:
Have you attached the Record of Expired or Soon to be Expired Medicines
Forms (page 5 and 6)
Have you packaged expired Section 1 medicines for return to the Regional
Hospital Pharmacy (page 5 and 6)
All expired / soon to expire medicines listed in Section 1 of the EMK Order Form must be
returned to the relevant Regional Hospital Pharmacy for destruction once new stock is
supplied. The Pharmacy will not accept return of any medicines unless accompanied by the
completed Record of Expired or Soon to Expire Medicines. Subsequent EMK orders will
not be processed until all outstanding unwanted or expired medicines are returned to
the Regional Hospital Pharmacy.
Note Section 2 medicines are not required to be returned to the Regional hospital
Pharmacy and may be disposed of on site. See Section 4.2.4 of the EMK Atlas
document.
Medicines ordered must match those listed on the Record of Use of Medicines and
Record of Expired or Soon to Expire Medicines forms.
Where the pharmacy detects a discrepancy between the records and the medicines
ordered, the order form and records will be returned to the EMK holder to be
completed/corrected and resubmitted.
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Page 2
Review Due: September 2018
EMERGENCY MEDICAL KIT ORDER – FORM
REMOTE HEALTH– Section 16: PHARMACY
REGISTER FOR MORPHINE (10mg/mL in 1mL ampoule)
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It is a requirement under the NT Medicines, Poisons and Therapeutic Goods Act and Regulations to maintain a register for Morphine held in EMKs
Each dealing with Morphine (receiving stock, administering to a person, or returning stock) must be recorded in the register. See Section 4.4.3
Emergency Medical Kits for an example of recording in the Register for Morphine
Each administration of Morphine to a person must be notified to the Medicines and Poisons Control within seven (7) days of the event
A monthly inventory of Morphine must be recorded in the register
A copy of the register MUST be submitted to the Regional Hospital Pharmacy with each order
If this register is not maintained, further supply of Morphine may be withheld or Kit authorisation revoked.
Licence / Property Name:
Date
Time
Patient Name or
Supplying Pharmacy
Name
Patient Address or
Supplying Pharmacy
Address
Amount
received
or given
Amount
discarded
Balance
(when relevant)
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Doctor’s Name
(Duty RMP)
Page 3
Review Due: September 2018
Name & Signature of
person receiving or
giving the Morphine
EMERGENCY MEDICAL KIT ORDER – FORM
REMOTE HEALTH– Section 16: PHARMACY
RECORD OF USE OF MEDICINES FORM
NOTES:



Record supply of medicine from Section 1 of the EMK Order Form (including usage and wastage) for an episode of care and send to the PHC DMS.
Maintain a record of the use of Medicines listed in Section 1 and 2. This MUST be submitted to the Regional Hospital Pharmacy with the next order.
Further supply of medicines may be withheld or Kit authorisation revoked if this record of supply is not received.
Licence / Property Name:
Date
Time
Patient’s Name
DOB
Medicine
Amount
given
Amount
Discarded
(when relevant)
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Doctor’s Name
(Duty RMP)
Page 4
Review Due: September 2018
Name & Signature of
person giving the
Medicine
EMERGENCY MEDICAL KIT ORDER – FORM
REMOTE HEALTH– Section 16: PHARMACY
RECORD OF EXPIRED OR SOON TO EXPIRE MEDICINES FORM - 1
NOTE: Unwanted or expired medicines listed in Section 1 of the EMK Order Form must be returned to the relevant Regional Hospital Pharmacy for
destruction once new items are supplied. Further supply of these medicines will not be processed until the unwanted or expired medicines have been
returned to the Regional Hospital Pharmacy.
A copy of the completed Record of Expired or Soon to Expire Medicines Form/s must be provided with the returned medicines. The pharmacy will not
accept return of medicines without this accompanying paperwork.
Licence / Property Name:
Date
Medicine
Quantity
Batch Number
Expiry Date
Section 1(a): Schedule 8 / Restricted Schedule 4 Medicines
Morphine 10mg/mL (1mL) amp
Paracetamol 500mg/ Codeine 30mg tablet
(Panadeine Forte / Codalgin Forte)
Midazolam 5mg/mL (1mL) amp
Kit Holder’s Signature:
Regional Hospital Pharmacy:
DATE RECEIVED
PHARMACIST SIGNATURE
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
COPY RETURNED TO KIT HOLDER
Page 5
Review Due: September 2018
EMERGENCY MEDICAL KIT ORDER – FORM
REMOTE HEALTH– Section 16: PHARMACY
RECORD OF EXPIRED OR SOON TO EXPIRE MEDICINES FORM – 2
NOTE: Unwanted or expired medicines listed in Section 1 of the EMK Order Form must be returned to the relevant Regional Hospital Pharmacy. Further
orders will not be processed until the unwanted or expired medicines have been returned to the Regional Hospital Pharmacy. The pharmacy will not accept
return of medicines without this accompanying paperwork.
Licence / Property Name:
Date
Medicine
Quantity
Batch
Number
Expiry
Date
Date
Medicine
Quantity
Batch
Number
Expiry
Date
All other Medicines listed in Section 1
Metoclopramide 5mg/mL (2mL) amp
Prednisolone 5mg tabs
Promethazine 25mg/mL (2mL) amp
Prednisolone 25mg tabs
Adrenaline 1:1000 1mg/mL amp
Promethazine 10mg tabs
Amoxycillin 500mg tabs/caps
Probenicid 500mg tabs
Cephalexin 500mg caps
Salbutamol 100mcg inhaler
Dicloxacillin 500mg caps
Amoxycillin 250mg/5mL susp
Doxycycline 100mg tabs/caps
Roxithromycin 50mg – dispersible tabs
Roxithromycin 150mg tabs
Flucloxacillin 250mg/5mL susp
Metronidazole 200mg tabs
Penicillin V 250mg/5mL susp
Nitrofurantoin 100mg caps
Sulfamethoxazole/Trimethoprim susp
Sulfamethoxazole/Trimethoprim tabs
Loratadine 1mg/mL syrup
Isosorbide 5mg S/L tabs
Ciprofloxacin 0.3% ear drops
Loperamide 2mg tabs/caps
Chloramphenicol 1% eye ointment
Metoclopramide 10mg tabs
Activated Charcoal 50g/250mL susp
Kit Holder’s Signature:
Regional Hospital Pharmacy:
DATE RECEIVED
PHARMACIST SIGNATURE
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
COPY RETURNED TO KIT HOLDER
Page 6
Review Due: September 2018
EMERGENCY MEDICAL KIT ORDER – FORM
REMOTE HEALTH– Section 16: PHARMACY
ORDER FORM
SECTION ONE
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Section 1(a) items are Schedule 8 / Restricted Schedule 4 Medicines
Section 1(b-h) items are Scheduled Medicines
Medical advice MUST be sought before any item in Sections 1 are used
A Record of Use of Medicines Form for all medicines must be kept
When ordering please enter a number in the ‘Required’ column
Emergency Medical Kit for:
Accredited for intramuscular injections?
Yes
No
Signature of Kit Holder:
Date:
Certified by PHC DMS:
Date:
Number
GENERIC Name of Medicine
(Brand Name)
Unit
Maximum
Allowed
Required
Pharmacy
Use Only
Section 1(a): Schedule 8 / Restricted Schedule 4 Medicines
11
Morphine 10mg/mL (1mL)
12
Paracetamol 500mg/Codeine 30mg
(Panadeine Forte / Codalgin Forte)
13
Midazolam 5mg/mL (1mL)
Supplied
Amp
2
Tablet
20
Amp
5
Substances in Section 1(a) will not be supplied without the PHC DMS signature
Signature of PHC DMS authorising
controlled substances:
Date:
Section 1(b): Injections
14
15
16
Metoclopramide 5mg/mL (2mL)
(Maxolon)
Promethazine 25mg/mL (2mL)
(Phenergan)
Adrenaline 1:1000 1mg/mL (1mL)
Amp
2
Amp
2
Amp
5
20’s
2
20’s
2
24’s
2
7’s
4
10’s
1
21’s
2
Section 1(c): Antibiotics – Adult
20
21
22
23
24
25
Amoxycillin 500mg tablets/capsules
(Amoxil, Cilamox, Moxacin)
Cephalexin 500mg capsules
(Ibilex, Keflex, Cilex)
Dicloxacillin 500mg capsules
(Diclocil, Distaph)
Doxycycline 100mg tablets/capsules
(Doxylin, Doryx)
Roxithromycin 150mg tablets
(Rulide, Biaxig)
Metronidazole 200mg tablets
(Flagyl, Metrogyl)
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Page 7
Review Due: September 2018
REMOTE HEALTH– Section 16: PHARMACY
Number
26
27
GENERIC Name of Medicine
(Brand Name)
Nitrofurantoin 100mg capsules
(Macrodantin)
Sulfamethoxazole/Trimethoprim 400mg/80mg
(Bactrim, Septrin, Resprim) tablets
EMERGENCY MEDICAL KIT ORDER – FORM
Unit
Maximum
Allowed
30’s
2
10’s
4
100’s
1
12’s
1
25’s
1
60’s
1
30’s
1
50’s
1
100’s
1
INH
2
Bottle
4
10’s
1
Bottle
1
Bottle
2
Bottle
2
Bottle
1
Bottle
2
Tube
2
Bottle
1
Required
Supplied
Section 1(d): Adult
28
29
30
31
32
33
34
35
Isosorbide 5mg S/L tablets
(Isordil)
Loperamide 2mg tablets/capsules
(Imodium, Gastro-stop)
Metoclopramide 10mg tablets
(Maxolon, Pramin)
Prednisolone 5mg tablets
(Panafcortelone, Solone)
Prednisolone 25mg tablets
(Panafcortelone, Solone)
Promethazine 10mg tablets
(Phenergan)
Probenicid 500mg tablets
(Pro-Cid)
Salbutamol 100mcg inhaler
(Ventolin, Asmol)
Section 1(e): Antibiotics – Child
36
37
38
39
40
Amoxycillin 250mg/5mL suspension
(Amoxil, Alphamox, Cilamox)
Roxithromycin 50mg - dispersible tablets
(Rulide D, Biaxsig D)
Flucloxacillin 250mg/5mL suspension
(Flopen)
Penicillin V 250mg/5mL suspension
(Phenoxymethylpenicillin)
Sulfamethoxazole/Trimethoprim
200mg/40mg/5mL suspension
(Bactrim, Septrin, Resprim)
Section 1(f): Child
41
Loratadine 1mg/mL syrup
(Claratyne)
Section 1(g): Antibiotic Ear & Eye Medicines
42
43
Ciprofloxacin 0.3% ear drops
(Ciloxan)
Chloramphenicol 1% eye ointment
(Chlorsig, Chloromycetin)
Section 1(h): Emergency Items
44
Activated Charcoal 50g/250mL suspension
(Carbosorb)
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Page 8
Review Due: September 2018
REMOTE HEALTH– Section 16: PHARMACY
EMERGENCY MEDICAL KIT ORDER – FORM
SECTION TWO
 Please ensure that any medicines information literature / Consumer Medicine Information (CMI) is
carefully examined and their instructions adhered to during treatment
 This section includes items that do not necessarily require the authorisation of a doctor. However,
seeking medical advice is still strongly recommended
 A Record of Use of Medicines Form for all medicines must be kept
 When ordering please enter a number in the ‘Required’ column
GENERIC Name of Medicine
(Brand Name)
Number
Unit
Maximum
Allowed
Bottle
500mL
1
96’s
1
50’s
2
100’s
1
200mL
1
Required
Supplied
Section 2(a): Internal Medicines - Adult
70
71
72
73
74
Aluminium/Magnesium oral liquid
(Gastrogel, Mylanta)
Aspirin 300mg effervescent tablets
(Disprin, Solprin)
Ibuprofen 200mg tablets
(Rafen, Brufen, Nurofen)
Paracetamol 500mg tablets/capsules
(Panadol, Panamax, Dymadon)
Bromhexine Cough Mixture 4mg/5mL
(Bisolvon)
Section 2(b): Internal Medicines - Child
75
76
Oral Rehydration Salts sachets
(Gastrolyte, Repalyte, ORS)
Paracetamol 120mg/5mL oral liquid
(Panadol, Dymadon, Panamax)
Box
10
Bottle
100mL
4
2
Section 2(c): External Medicines for Skin
77
Clotrimazole 1% cream
(Canesten, Clonea)
78
Chlorhexidine/Cetrimide irrigation
79
Povidine Iodine 10% ointment
(Betadine, Viodine)
Tube
20g
Bottle
30mL
Tube
25g
1
6
2
Section 2(d): Other Medicines
81
Naphazoline/Antazoline eye drops
(Naphcon A)
Bottle
15mL
Amp
30mL
82
Sodium Chloride 0.9% irrigation
83
Clotrimazole 500mg vaginal pessary
(Canesten, Clofeme)
Pess
1
84
Clove Oil
Bottle
10mL
1
Spacer
2
Mask
2
1
6
Section 2(e): Assorted Pharmacy Items
85
Adult / Child Spacer
(Breath-A-Tech)
86
Face Mask - Child
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Page 9
Review Due: September 2018
EMERGENCY MEDICAL KIT ORDER – FORM
REMOTE HEALTH– Section 16: PHARMACY
SECTION THREE
 When ordering please enter a number in the ‘Required’ column.
Unit
Maximum
Allowed
Medicine Measure Disposable 30mL
Single
2
Hypodermic Needle Disposable 23 Gauge
Single
6
Drawing-up Needles Disposable 18 or 19 Gauge
Single
6
Hypodermic Syringe Disposable 1mL
(for Anaphylaxis Kit)
Single
2
Hypodermic Syringe Disposable 5mL
Single
4
Alcohol Injection Swabs
Single
20
Sharps Container 1.4 Litre
Single
1
Flexible Fabric Dressing Strip 40 or 75mm x 1m
Single
2
Pkt of 2
10 pkts
Bandage Crepe Supportive 5cm
Single
5
Bandage Crepe Supportive 15cm
Single
5
Bandage Non-Supportive 5cm
Single
4
Bandage Non-Supportive 7.5cm
Single
4
Gauze Paraffin - Sterile 10cm x 10cm
Single
2
Eye Pad - Sterile
Single
10
Pkt of 10
3 pkts
Digital Clinical Thermometer
Single
1
Triangular Bandage
Single
2
Pkt of 5
3 pkts
Single
20 pkts
Tube 20g
3
Item
Cotton Tipped Applicators - Sterile
Skin Closure
Square Gauze Dressing
Dressing Low Adherent 7.5cm x 5 cm
Dressing Wound Premixed Interactive Gel
(SoloSite)
Required
Supplied
If any requested item has not arrived with your
order please re-order it on a new Order Form.
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Page 10
Review Due: September 2018
REMOTE HEALTH– Section 16: PHARMACY
EMERGENCY MEDICAL KIT ORDER – FORM
SECTION FOUR
This Section contains general information.
Section Four (a)
Sending an EMK Order and Record of Use of Medicines Form:
Central Australia
Top End
Mail Address:
The Chief Pharmacist
Pharmacy Department
Alice Springs Hospital
PO Box 2234
Alice Springs NT 0871
The Pharmacist
Katherine Hospital
PO Box 73
Katherine
Northern Territory NT 0852
Phone:
Fax:
E-Mail Address:
(08) 8951 7570
(08) 8951 7766
(08) 8973 9236
(08) 8973 9010
alicespringspharmacy.dhcs@nt.gov.au
KDHPharmacy.THS@nt.gov.au
Section Four (b)
Primary Health Care Director of Medical Services Contact Information:
Central Australia
Top End
Phone:
Fax:
(08) 8951 7010
(08) 8980 0753
Section Four (c)
Consulting a Duty Rural Medical Practitioner:
Central Australia
Phone:
08 8951 7840
(08) 8922 7638
(08) 8922 7799
Top End
08 8922 8888
with call divert to Alice Springs Hospital for
after-hours service
Section Four (d)
Medicines and Poisons Control Contact Information:
Phone:
Fax:
Email:
(08) 8922 7341
(08) 8922 7200
poisonscontrol@nt.gov.au
Medical Kits website:
http://www.health.nt.gov.au/Environmental_Health/Medicines_and_Poisons
_Control/Medical_Kits
Section Four (e)
Information for Emergency Kit Holders
For further information please refer to the:
 Emergency Medicines Kit Medical Guide (hard copy / USB)
 Remote Health Atlas website: Emergency Medical Kits:
http://remotehealthatlas.nt.gov.au/emergency_medical_kits.pdf
 NT Medicines, Poisons and Therapeutic Goods Act and Regulations via NT Legislation
database:
http://notes.nt.gov.au/dcm/legislat/legislat.nsf/d989974724db65b1482561cf0017cbd2?
OpenView&Start=1&Count=300&Expand=13#13
Form developed by: PHC Director of Medical Services & Quality & Safety Team
Form endorsed by: PHC Director of Medical Services & PHC NT-wide Leadership Committee
Release Date: May 2008
Reviewed: Aug 12,Oct 12, Nov 12, Sept 15,
Page 11
Review Due: September 2018