CIS/Mosaiq® e-prescribing addition/variation request form

All requested additions/variations to the e-prescribing system must be made using this form.

Requests will be discussed and prioritised at LCASE Mosaiq Clinical Group.

Please complete the information as fully as possible then email to .

If you require assistance or wish to discuss further then please contact 020 7188 7188 (ext 52745).

Contact Information (Applicant to complete)

Request submitted by:

Date requested:

Role/Job Title:

Email address:

Contact telephone number:

Request details (Applicant to complete)

What is the addition/variation being requested?

Addition of a new chemotherapy regimen

Update or change to an existing regimen(s)

Removal of an existing regimen(s)

Addition of a new supportive medicine

Update or change to an existing supportive medicine

Other (detail below)

(please specify here)

Please list each of the regimens to be added/changed/removed: (type here)

Please provide reasons why the variation is required:(type here)

Prioritisation (Applicant to complete)

Approximately how many patients receive the affected regimen(s) per year?

1-1010-3030-5050+

Have there been any incidents (IR1s), complaints, errors or near misses with the affected regimen(s)?

YesNoIf Yes, please provide details (type here)

Is the affected regimen used at multiple sites?

Yes No If Yes, please provide details (type here)

Is there cross site transfer of prescriptions or are there other significant pathway related issues that CIS/Mosaiq® could resolve for the affected regimen?

Yes No If Yes, please provide details (type here)

Are there any financial implications to the directorate/Trust relating to this addition/variation?

Yes No If Yes, please provide details (type here)

Please list any groups or committees that have discussed this change or provide any other supporting information:(type here)

**This is the end of the form for applicants**

Thank you for completing this form, please submit it via email to:

For Mosaiq e-prescribing team use only (prior to LCASE MCG):

Is this an Urgent request?Yes (notify LCASE MCG Chair)No

Is additional information required? YesNo Details (type here)

Number of regimens affected by this request:(type here)

Appendix 1Appendix 2Appendix 5

Estimated time required to do the work:(type here)

0 / 1 / 2 / 3 / 4 / Score
How many patients receive the affected regimen(s) per year? / - / 1-10 / 10-30 / 30-50 / 50+
Have there been any incidents (IR1s), complaints, errors or near misses with the affected regimen(s)? / No / - / Yes (Near miss) / Yes (Incident Complaint or Error) / -
Is the affected regimen used at multiple sites? / No / 2 sites / 3 sites / 4 sites / 5 sites
Is there cross site transfer of prescriptions or are there other significant pathway related issues that CIS/Mosaiq® could resolve for the affected regimen? / No / - / Yes / - / -
Are there any financial implications to the directorate/Trust relating to this addition/variation? / No / - / Yes / - / -
Other factors / Score based on the severity of the factors stated
Total:
Prioritisation Category / Total Score
High Priority / 11+
Medium Priority / 6-10
Low Priority / 1-5

Date of review and addition to Work Plan:(type here)

Request ID number:(type here)

For Mosaiq e-prescribing team use only (after LCASE MCG):

Date discussed at LCASE MCG:(type here)

Comments from LCASE MCG:(type here)

Staff allocated for validation:(type here)

Date Work Plan updated:(type here)

Applicant informed of outcome: YesDate: (type here)

** N.B. This page is for Mosaiq e-prescribing team use only**

Mosaiq e-prescribing teamPage 1 of 2December 2014 – version 3