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IV Infusion Record Sheet

This is a legal requirment under the Medicines (Standing Order) Regulation 2002 and Medicine Act 1983 (Section 29) All records are accurate and recorded. This is the responsilbiity of the clinician working under the Standing Order Regulations.


Birthday
Month
Day
Year

PATIENT HISTORY

Is this the first time receiving infusion today?
Yes
No

Any form of infusion via an IV Line for medical and non medical treatments

Any Known drug allergies
Yes
No

Allergy is defined as having Hives,Swelling of Airways, Shock. If patient has any known drug allergies please write below:

Patient Pregnant or Breast feeding?
Yes
No

If Pregnant please write how many weeks. Check with Pharmacist if contra-indicated during Pregnancy

Does Patient have any medical conditions
Yes, If so what?
No

If patient has any known medical conditions please write below:

Does the Patient take any regular medications?

If on medication check for interactions and safety. You can check this by going to www.nzf.org

PATIENT VITALS/OBS

NORMAL LESS THAN 120 and LESS THAN 80

ELEVATED 120 – 129 and LESS THAN 80 HIGH BLOOD PRESSURE (HYPERTENSION) STAGE 130 – 139 or 80 – 89

Describe patient presentation

Required for Iron infusion

Consultation Notes

Consent for Infusions

Medicines go through an assessment and approval process before they can be supplied in

New Zealand. This is to ensure that the medicines supplied meet the required standards of

quality and are safe and effective. These are known as approved medicines.

  • Sometimes your healthcare professional (prescriber) may need to use an unapproved medicine or an approved medicine in a new way.

  • If this is the case, the prescriber must explain to you what is being prescribed and why, and

  • you must give your consent if you agree. This is required under the Code of Health and

  • Disability Services Consumers' Rights.

  • If you agree to be given an unapproved medicine (sometimes called a section 29 medicine),

  • information about the supply must be held by the manufacturer or importer, and a subset of this sent to Medsafe, Ministry of Health. Your prescriber will tell you about this.

  • Section 29 medicines are manufactured, compounded or imported by a pharmacist in a pharmacy.


The intravenous infusion you are receiving today is an elective service, and further research is needed to confirm its effectiveness for medical purposes. The LAB and its clinicians have informed you about the potential side effects, which are rare but can be serious, such as


Anaphylaxis—a severe allergic reaction to the infused drug. Although this is uncommon, it’s important to recognize

the symptoms, which include difficulty breathing, swelling of the lips or mouth, and the formation of a rash.

Common expected side effects include nausea, vomiting, dizziness or light-headedness, and hot flushes. If you experience any of these symptoms, please inform us immediately so we can adjust

your infusion accordingly.


Our clinician may request blood test results for screening purposes at the same time of your infusion or prior to your infusion. It is important you disclose your full medical conditions including history or

known allergy reactions.


By signing this consent form, you have been advised of the adverse effects of the infusions, have been provided information regarding the infusion, and have been advised of the purpose and procedure of the intravenous infusion.

Infusion Details

Infusion Start
Time
HoursMinutes

Normal Saline IV Bags must also be recorded

INFUSION DETAILS

IV Cannulation Site
LEFT ARM/WRIST
RIGHT ARM/WRIST
Cannulation Anatomy
Cephalic Vein
Medial Cubital Vein
Basilic Vein
Dorsal Metacarpal Vein
IV Catheter Size
22G
24G
Number of Attempts in Cannulation
1
2
3

This should not exceed more than 2 times for the same clinician.

Infusion Completed Time
Time
HoursMinutes

Standing order doctor must be informed of any adverse events. Please inform your clinical lead.

Clinician
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WELLBEING & PLASTIC SURGERY

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@thelab.nz

09 418 1230

3/3 Akoranga Drive, Northcote
Auckland 0627

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