UTI or Cystitis Consultation

Patient Name

First

Last

SECTION 1 – Preconsultation Assessment

Layout

Check Inclusion Checklist for Nitrofurantoin Advance Supply

Female, 18 to 65 years
Previously sought advice from their GP about an uncomplicated UTI
Valid consent has been gained from a patient.
Requesting standby treatment i.e. undertaking activities that may increase chance of UTI

Check Exclusion Checklist for Nitrofurantoin Advance Supply

under 18 years of age or over 65 years
No valid consent has been gained
Male Patients
Patients who have previously experienced urinary tract infection with haematuria (visible or non-visible) where the underlying cause was not investigated by their GP or specialist.
Where upper urinary tract infection and other alternative diagnoses have not been excluded from a past UTI
Hypersensitivity to nitrofurantoin, other nitrofurans or any of the excipients
Mild to severe renal impairment
Hepatic impairment.
Individuals with a G6PD deficiency.
Individuals with acute porphyria
Known or suspected pregnancy
Breast-feeding individuals
Concurrent administration with: ̵ Dapsone ̵ Prilocaine
Patients with a history of upper urinary tract infection (including pyelitis and pyelonephritis).
Patients with a history of complicated UTI
Individuals with an indwelling urinary catheter.
Patients who have been treated for a UTI in the last 3 months
Patients with an abnormal urinary tract renal calculus, vesicoureteric reflux, reflux nephropathy, neurogenic bladder, urinary obstruction or recent instrumentation
Patients requesting prophylaxis for urinary-tract infections.
Individuals experiencing flank or loin pain.
Patients with a temperature above 38°C (fever)
Patients who are immunosuppressed.
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption.
Patients with a risk factor for an abnormality of the urinary tract.
Patients with severe chronic recurrence of UTIs.
Patients who are still experiencing symptoms following a previous UTI.
Patients with: ̵ Anaemia ̵ Diabetes mellitus ̵ Electrolyte imbalance ̵ Debilitating conditions ̵ Peripheral neuropathy (including those susceptible to peripheral neuropathy) ̵ Pulmonary disease ̵ Vitamin B deficiency (particularly folate deficiency). ̵ Neurological disorders ̵ Allergic diathesis

Tick the one that applies

Patient is INcluded for Nitrofuratoin Advance
Patient is EXcluded for Nitrofuratoin Advance

Layout

Tick the one that applies (copy)

Patient is INcluded for Nitrofuratoin – Acute Cystitis
Patient is EXcluded for Nitrofuratoin – Acute Cystitis

SECTION 2 – Complete this session during consultation

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

Product Interactions

If patient is on additional medication, check PGD for any product interactions or BNF

Check PGD for cautions, dose, advice, maximum quantity and treatment

Action if excluded from Nitrofuratoin Advance or uncomplicated lower urinary tract infections in women

Refer to their doctor for medical assessment, treatment and advice.
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.
Discuss measures that the patient can take to reduce the risk of UTIs.

Action if patient declines the service

Refer to their doctor for medical assessment, treatment and advice.
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.
Discuss measures that the patient can take to reduce the risk of UTIs.

Document reason for exclusion, patient decline and any advice given or action taken in patient’s clinical records

Healthcare Professional Name

First

Last

GPHC Number

Date

Time

SECTION 1 – Preconsultation Assessment

SECTION 2 – Complete this session during consultation

Product Interactions

Check PGD for cautions, dose, advice, maximum quantity and treatment

Start Assessment

Complete Patient Details