Respiratory Consultation

Patient Name

First

Last

SECTION 1

Preconsutation Assessment

.

Patient Consent

obtained from the patient/carer who does not want to consult with their GP and would prefer to access treatment from the PGD user

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Inclusion Checklist

Patients from 16 years of age.
Patients must have seen their GP or nurse in the last year and have had a salbutamol 100mcg MDI inhaler prescribed for them within the last year.

Exclusion Checklist

Patients with severely impaired absorption from the gut.
Patients for whom no valid consent has been received.
Hypersensitivity to the active substance(s) or to any of the excipients or trace residuals in salbutamol 100mcg MDI inhaler. See section 2 and 6.1 of the relevant Summary of Product Characteristics (SPC).
Patients who do not wish for their GP to be contacted. Each time a salbutamol 100mcg MDI inhaler is supplied by PGD the patient’s GP must be sent a copy of the completed form. If the patient does not have a contactable GP they will be excluded from treatment.
Patients who do not satisfy the PGD user that they have been prescribed salbutamol 100mcg MDI inhaler before for the treatment of asthma.
Patients who have not seen their GP or nurse in the last year and have not had a salbutamol 100mcg MDI inhaler on prescription within the last year.
Salbutamol 100mcg MDI inhalers cannot be supplied by PGD to patients who are currently using their inhalers more than 4 times daily.
The patient is between the ages of 16-18 years if not accompanied by a legal guardian.

Tick the one that applies

Patient is INcluded for Salbutmol MDI Treatment
Patient is EXcluded for Salbutmol MDI Treatment

SECTION 2 – Complete this session during consultation

Salbutamol 100mcg metred dose inhaler (MDI) can be used as relief medication to manage mild, moderate and severe asthma, including the prevention of asthma attacks induced by exercise or exposure to allergens. (Obkectives – Relief and prevention of asthma symptoms)

Type of consultation

Video
Telephone
Walk In

Check patient ID presented e,g passport, Drivers License or Photocard

Passport
Drivers License
Photocard
Other

If other please specify

Refer to PGD to review caution based on patients assessment

Outcome of assessment

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Action if excluded

Discuss with patient and document the reasons for exclusion from treatment under the PGD.
• If the patient has consented, refer them to their GP and/or inform their GP.
• Signpost to other services if appropriate.
• Document the reasons for exclusion and any action taken, in the patient’s medication record.
• When treatment is postponed reschedule as appropriate

Action if patient
declines treatment

• Ensure patient/carer fully understands the risks of declining the service.
• Advise the patient/carer about the benefits of the service.
• Refer patient to GP if appropriate.
• Document the reasons for declining the service and any action taken, including advice given to the patient.
• Reschedule treatment if appropriate.
• Explain NHS eligibility for this service where appropriate.

Note to prescriber

There are many different generic and branded versions of salbutamol 100mcg MDI inhalers. The PGD user should ensure (where possible) that the formulation supplied via this PGD matches the specific formulation the patient has had in the past. Examples of products include: Ventolin, Salamol, Airomir.

Refer to PGD for dose, administration, route, advice, minimum/maximum supply, adverse reaction.

Healthcare Professional Name

First

Last

GPHC Number

Date

SECTION 1

Preconsutation Assessment

SECTION 2 – Complete this session during consultation

Refer to PGD to review caution based on patients assessment

Action if excluded

Action if patient
declines treatment

Note to prescriber

Refer to PGD for dose, administration, route, advice, minimum/maximum supply, adverse reaction.

Start Assessment

Complete Patient Details

SECTION 1

Preconsutation Assessment

SECTION 2 – Complete this session during consultation

Refer to PGD to review caution based on patients assessment

Action if excluded

Action if patient declines treatment

Note to prescriber

Refer to PGD for dose, administration, route, advice, minimum/maximum supply, adverse reaction.

Start Assessment

Complete Patient Details

Action if patient
declines treatment