Nurse or Practitioner in Charge*
First
Last
Trust -- Please select -- Airedale NHS Foundation Trust Alder Hey Children's NHS Foundation Trust Ashford and St Peter's Hospitals NHS Foundation Trust Avon and Wiltshire Mental Health Partnership NHS Trust Barking, Havering and Redbridge University Hospitals NHS Trust Barnet, Enfield and Haringey Mental Health NHS Trust Barnsley Hospital NHS Foundation Trust Barts Health NHS Trust Bedford Hospital NHS Trust Berkshire Healthcare NHS Foundation Trust Betsi Cadwaladr University Health Board Birmingham and Solihull Mental Health NHS Foundation Trust Birmingham Community Healthcare NHS Foundation Trust Birmingham Women's and Children's NHS Foundation Trust Black Country Healthcare NHS Foundation Trust Blackpool Teaching Hospitals NHS Foundation Trust Bolton NHS Foundation Trust Bradford District NHS Foundation Trust Bradford Teaching Hospitals NHS Foundation Trust Bridgewater Community Healthcare NHS Foundation Trust Brighton and Sussex University Hospitals NHS Trust Buckinghamshire Healthcare NHS Trust Burton Hospitals NHS Foundation Trust Calderdale and Huddersfield NHS Foundation Trust Cambridge University Hospitals NHS Foundation Trust Cambridgeshire and Peterborough NHS Foundation Trust Cambridgeshire Community Services NHS Trust Camden and Islington NHS Foundation Trust Central and North West London NHS Foundation Trust Central London Community Healthcare NHS Trust Chelsea and Westminster Hospital NHS Foundation Trust Cheshire and Wirral Partnership NHS Foundation Trust Chesterfield Royal Hospital NHS Foundation Trust City Hospitals Sunderland NHS Foundation Trust Cornwall Partnership NHS Foundation Trust Countess Of Chester Hospital NHS Foundation Trust County Durham and Darlington NHS Foundation Trust Coventry and Warwickshire Partnership NHS Trust Croydon Health Services NHS Trust Cumbria Northumberland Tyne and Wear NHS Foundation Trust Dartford and Gravesham NHS Trust Derbyshire Community Health Services NHS Foundation Trust Derbyshire Healthcare NHS Foundation Trust Devon Partnership NHS Trust Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Dorset County Hospital NHS Foundation Trust Dorset Healthcare University NHS Foundation Trust Dudley Integrated Health and Care NHS Trust East and North Hertfordshire NHS Trust East Cheshire NHS Trust East Kent Hospitals University NHS Foundation Trust East Lancashire Hospitals NHS Trust East London NHS Foundation Trust East Midlands Ambulance Service NHS Trust East Of England Ambulance Service NHS Trust East Suffolk and North Essex NHS Foundation Trust East Sussex Healthcare NHS Trust Epsom and St Helier University Hospitals NHS Trust Essex Partnership University NHS Foundation Trust Frimley Health NHS Foundation Trust Gateshead Health NHS Foundation Trust George Eliot Hospital NHS Trust Gloucestershire Care Services NHS Trust Gloucestershire Health and Care NHS Foundation Trust Gloucestershire Hospitals NHS Foundation Trust Great Ormond Street Hospital for Children NHS Foundation Trust Great Western Hospitals NHS Foundation Trust Greater Manchester Mental Health NHS Foundation Trust Guy's and St Thomas' NHS Foundation Trust Hampshire Hospitals NHS Foundation Trust Harrogate and District NHS Foundation Trust Hertfordshire Community NHS Trust Hertfordshire Partnership University NHS Foundation Trust Homerton University Hospital NHS Foundation Trust Hounslow and Richmond Community Healthcare NHS Trust Hull University Teaching Hospitals NHS Trust Humber Teaching NHS Foundation Trust Imperial College Healthcare NHS Trust Isle Of Wight NHS Trust James Paget University Hospitals NHS Foundation Trust Kent and Medway NHS and Social Care Partnership Trust Kent Community Health NHS Foundation Trust Kettering General Hospital NHS Foundation Trust King's College Hospital NHS Foundation Trust Kingston Hospital NHS Foundation Trust Lancashire & South Cumbria NHS Foundation Trust Lancashire Teaching Hospitals NHS Foundation Trust Leeds and York Partnership NHS Foundation Trust Leeds Community Healthcare NHS Trust Leeds Teaching Hospitals NHS Trust Lewisham and Greenwich NHS Trust Lincolnshire Community Health Services NHS Trust Lincolnshire Partnership NHS Foundation Trust Liverpool Heart and Chest NHS Foundation Trust Liverpool University Hospitals NHS Foundation Trust Liverpool Women's NHS Foundation Trust London Ambulance Service NHS Trust London North West University Healthcare NHS Trust Luton and Dunstable University Hospital NHS Foundation Trust Maidstone and Tunbridge Wells NHS Trust Manchester University NHS Foundation Trust Medway NHS Foundation Trust Mersey Care NHS Foundation Trust Mid and South Essex NHS Foundation Trust Mid Cheshire Hospitals NHS Foundation Trust Mid Yorkshire Hospitals NHS Trust Midlands Partnership NHS Foundation Trust Milton Keynes University Hospital NHS Foundation Trust Moorfields Eye Hospital NHS Foundation Trust Norfolk and Norwich University Hospitals NHS Foundation Trust Norfolk and Suffolk NHS Foundation Trust Norfolk Community Health and Care NHS Trust North Bristol NHS Trust North Cumbria Integrated Care NHS Foundation Trust North Cumbria University Hospitals NHS Trust North East Ambulance Service NHS Foundation Trust North East London NHS Foundation Trust North Middlesex University Hospital NHS Trust North Staffordshire Combined Healthcare NHS Trust North Tees and Hartlepool NHS Foundation Trust North West Ambulance Service NHS Trust North West Anglia NHS Foundation Trust North West Boroughs Healthcare NHS Foundation Trust Northampton General Hospital NHS Trust Northamptonshire Healthcare NHS Foundation Trust Northern Devon Healthcare NHS Trust Northern Lincolnshire and Goole NHS Foundation Trust Northumbria Healthcare NHS Foundation Trust Nottingham University Hospitals NHS Trust Nottinghamshire Healthcare NHS Foundation Trust Oxford Health NHS Foundation Trust Oxford University Hospitals NHS Foundation Trust Oxleas NHS Foundation Trust Pennine Acute Hospitals NHS Trust Pennine Care NHS Foundation Trust Poole Hospital NHS Foundation Trust Portsmouth Hospitals NHS Trust Project Nightingale NHS Trust Queen Victoria Hospital NHS Foundation Trust Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust Rotherham Doncaster and South Humber NHS Foundation Trust Royal Berkshire NHS Foundation Trust Royal Brompton and Harefield NHS Foundation Trust Royal Cornwall Hospitals NHS Trust Royal Devon and Exeter NHS Foundation Trust Royal Free London NHS Foundation Trust Royal National Orthopaedic Hospital NHS Trust Royal Papworth Hospital NHS Foundation Trust Royal Surrey NHS Foundation Trust Royal United Hospitals Bath NHS Foundation Trust Salford Royal NHS Foundation Trust Salisbury NHS Foundation Trust Sandwell and West Birmingham Hospitals NHS Trust Services Hub For East Sussex Healthcare NHS Trust Sheffield Children's NHS Foundation Trust Sheffield Health and Social Care NHS Foundation Trust Sheffield Teaching Hospitals NHS Foundation Trust Sherwood Forest Hospitals NHS Foundation Trust Shrewsbury and Telford Hospital NHS Trust Shropshire Community Health NHS Trust Solent NHS Trust Somerset Partnership NHS Foundation Trust South Central Ambulance Service NHS Foundation Trust South East Coast Ambulance Service NHS Foundation Trust South London and Maudsley NHS Foundation Trust South Tees Hospitals NHS Foundation Trust South Tyneside And Sunderland NHS Foundation Trust South Tyneside NHS Foundation Trust South Warwickshire NHS Foundation Trust South West London and St George's Mental Health NHS Trust South West Yorkshire Partnership NHS Foundation Trust South Western Ambulance Service NHS Foundation Trust Southern Health NHS Foundation Trust Southport and Ormskirk Hospital NHS Trust St George's University Hospitals NHS Foundation Trust St Helens and Knowsley Hospitals NHS Trust Stockport NHS Foundation Trust Surrey and Borders Partnership NHS Foundation Trust Surrey and Sussex Healthcare NHS Trust Sussex Community NHS Foundation Trust Sussex Partnership NHS Foundation Trust Tameside Hospital NHS Foundation Trust Taunton and Somerset NHS Foundation Trust Tavistock and Portman NHS Foundation Trust Tees, Esk and Wear Valleys NHS Foundation Trust The Christie NHS Foundation Trust The Clatterbridge Cancer Centre NHS Foundation Trust The Dudley Group NHS Foundation Trust The Hillingdon Hospitals NHS Foundation Trust The Newcastle Upon Tyne Hospitals NHS Foundation Trust The Princess Alexandra Hospital NHS Trust The Queen Elizabeth Hospital, King's Lynn. NHS Foundation Trust The Rotherham NHS Foundation Trust The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust The Royal Marsden NHS Foundation Trust The Royal Orthopaedic Hospital NHS Foundation Trust The Royal Wolverhampton NHS Trust The Walton Centre NHS Foundation Trust Torbay and South Devon NHS Foundation Trust United Lincolnshire Hospitals NHS Trust University College London Hospitals NHS Foundation Trust University Hospital of Derby and Burton NHS Foundation Trust University Hospital Southampton NHS Foundation Trust University Hospitals Birmingham NHS Foundation Trust University Hospitals Bristol and Weston NHS Foundation Trust University Hospitals Coventry and Warwickshire NHS Trust University Hospitals Dorset NHS Foundation Trust University Hospitals Of Leicester NHS Trust University Hospitals Of Morecambe Bay NHS Foundation Trust University Hospitals of North Midlands University Hospitals Plymouth NHS Trust Walsall Healthcare NHS Trust Warrington and Halton Hospitals NHS Foundation Trust West Hertfordshire Hospitals NHS Trust West London NHS Trust West Midlands Ambulance Service University NHS Foundation Trust West Suffolk NHS Foundation Trust Western Sussex Hospitals NHS Foundation Trust Whittington Health NHS Trust Wirral Community NHS Foundation Trust Wirral University Teaching Hospital NHS Foundation Trust Worcestershire Acute Hospitals NHS Trust Worcestershire Health and Care NHS Trust Wrightington, Wigan and Leigh NHS Foundation Trust Wye Valley NHS Trust Yeovil District Hospital NHS Foundation Trust York Teaching Hospital NHS Foundation Trust Yorkshire Ambulance Service NHS Trust
Hospital* -- Please select -- Abergele Hospital Andover War Memorial Hospital Arrowe Park Hospital Ashford Hospital Basildon University Hospital Basingstoke and North Hampshire hospital Benenden Hospital Birmingham City Hospital BMI The Chaucer Hospital Broomfield Hospital Cannock Chase Hospital Canvey NHS Outpatients Centre Charing Cross Hospital Cheltenham Hospital Churchill Hospital Colchester Hospital Darlington Hospital Denmark Hill Denmark Hill DSU Derriford Hospital Dorset County Hospital Evesham Community Hospital Fairfield General Hospital Glan Clwyd Hospital Gloucestershire Royal Hospital Homerton University Hospital Ipswich Hospital Kent and Canterbury Hospital King George Hospital Leigh Infirmary Lewisham Hospital Lister Hospital Lymington New Forest Hospital Malvern Community Hospital Medway Maritime Hospital New Cross Hospital The New QEII Hospital Nottingham City Hospital Oaks Hospital Orsett Hospital Peterborough City Hospital Poole Hospital Princess Alexandra Hospital Princess Royal Hospital Princess Royal University Hospital Queen Alexandra Hospital Queen Elizabeth Hospital Birmingham Queen Elizabeth Hospital- Woolwich Queen Elizabeth The Queen Mother Hospital Queen's Hospital Royal Bournemouth Hospital Royal Hampshire County Hospital Royal Shrewsbury Hospital Royal Stoke University Hospital Royal Sussex County Hospital Royal United Hospital Russells Hall Hospital Salisbury District Hospital Southampton General Hospital South Bristol Community Hospital Southend University Hospital Southmead Hospital St Margaret's Hospital St Marks Hospital St Mary's Hospital Stoke Mandeville Hospital St Thomas' Hospital The Grove The Princess Alexandra Hospital Torbay Hospital Will Adams NHS Treatment Centre William Harvey Hospital Worthing Hospital Wrexham Maelor Hospital Ysbyty Gwynedd Other
Other hospital*
Speciality* Ophthalmology
Subspecialty or Subspecialties* Days worked* Sat date*
DD slash MM slash YYYY
Sun date*
DD slash MM slash YYYY
Mon date*
DD slash MM slash YYYY
Tues date*
DD slash MM slash YYYY
Wed date*
DD slash MM slash YYYY
Thu date*
DD slash MM slash YYYY
Fri date*
DD slash MM slash YYYY
Confirmation of Staffing
In order for you and the team to be paid correctly and on time please ensure full names as per the staff report and start and finish times are completed.
Staff details
eg. Jane Doe RGN Procedure Room 1 Sat
Team start time - Sat* Team end time - Sat* Did you finish on time - Sat If No, please state the reason why
Team start time - Sun* Team end time - Sun* Did you finish on time - Sun If No, please state the reason why
Team start time - Mon* Team end time - Mon* Did you finish on time - Mon If No, please state the reason why
Team start time - Tues* Team end time - Tues* Did you finish on time - Tues If No, please state the reason why
Team start time - Wed* Team end time - Wed* Did you finish on time - Wed If No, please state the reason why
Team start time - Thu* Team end time - Thu* Did you finish on time - Thu If No, please state the reason why
Team start time - Fri* Team end time - Fri* Did you finish on time - Fri If No, please state the reason why
Did everyone turn up to the huddle - Sat Name and reason why staff did not attend - Sat*
Did everyone turn up to the huddle - Sun Name and reason why staff did not attend - Sun
Did everyone turn up to the huddle - Mon Name and reason why staff did not attend - Mon
Did everyone turn up to the huddle - Tues Name and reason why staff did not attend - Tues
Did everyone turn up to the huddle - Wed Name and reason why staff did not attend - Wed
Did everyone turn up to the huddle - Thu Name and reason why staff did not attend - Thu
Did everyone turn up to the huddle - Fri Name and reason why staff did not attend - Fri
You are responsible for ensuring information in this report is accurate as this a legal record. If are happy with above content please confirm.* Yes
Does your signature sheet match the staff listed on this report?* Yes
18 Week Support Signature Sheet complete and copy given to Trust link nurse?* For all days worked
Please state reason why*
Activity Breakdown Subspecialties
Please fill in the number of subspecialties running on the day.
Number of subspecialties - Sat* Please select all that apply. For example, if the number of subspecialties is 3, select 1, 2 and 3 - not just 3.
Number of subspecialties - Sun* Please select all that apply. For example, if the number of subspecialties is 3, select 1, 2 and 3 - not just 3.
Number of subspecialties - Mon* Please select all that apply. For example, if the number of subspecialties is 3, select 1, 2 and 3 - not just 3.
Number of subspecialties - Tues* Please select all that apply. For example, if the number of subspecialties is 3, select 1, 2 and 3 - not just 3.
Number of subspecialties - Wed* Please select all that apply. For example, if the number of subspecialties is 3, select 1, 2 and 3 - not just 3.
Number of subspecialties - Thu* Please select all that apply. For example, if the number of subspecialties is 3, select 1, 2 and 3 - not just 3.
Number of subspecialties - Fri* Please select all that apply. For example, if the number of subspecialties is 3, select 1, 2 and 3 - not just 3.
Patient Activity - Confirmation of timing and numbers for each session
Please fill in the room numbers and start/end times of the consultations for each subspecialty then confirm the total number of patients who are seen, cancelled, or did not attend. We are relying on your accuracy so that our financial information and feedback to the Trust is robust. For all patients treated, please ensure the numbers correspond with the patient clinical outcomes you return to 18 Week Support
Saturday - Subspecialty 1 Room Number - Sat 1*
Subspecialty - Sat 1* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sat 1* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sat 1* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sat 1*
No. of new patients seen - Sat 1*
No. of follow-ups seen - Sat 1*
No. of patients DNA - Sat 1*
No. of patients left before treatment - Sat 1*
No. of patients seen - Sat 1*
No. of patients with procedure - Sat 1*
No. of patients cancelled - Sat 1*
No. of new patients discharged - Sat 1*
No. of follow-ups discharged - Sat 1*
Total no. of patients discharged - Sat 1*
Saturday - Subspecialty 2 Room Number - Sat 2*
Subspecialty - Sat 2* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sat 2* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sat 2* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sat 2*
No. of new patients seen - Sat 2*
No. of follow-ups seen - Sat 2*
No. of patients DNA - Sat 2*
No. of patients left before treatment - Sat 2*
No. of patients seen - Sat 2*
No. of patients with procedure - Sat 2*
No. of patients cancelled - Sat 2*
No. of new patients discharged - Sat 2*
No. of follow-ups discharged - Sat 2*
Total no. of patients discharged - Sat 2*
Saturday - Subspecialty 3 Room Number - Sat 3*
Subspecialty - Sat 3* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sat 3* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sat 3* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sat 3*
No. of new patients seen - Sat 3*
No. of follow-ups seen - Sat 3*
No. of patients DNA - Sat 3*
No. of patients left before treatment - Sat 3*
No. of patients seen - Sat 3*
No. of patients with procedure - Sat 3*
No. of patients cancelled - Sat 3*
No. of new patients discharged - Sat 3*
No. of follow-ups discharged - Sat 3*
Total no. of patients discharged - Sat 3*
Saturday - Subspecialty 4 Room Number - Sat 4
Subspecialty - Sat 4* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sat 4* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sat 4* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sat 4*
No. of new patients seen - Sat 4*
No. of follow-ups seen - Sat 4*
No. of patients DNA - Sat 4*
No. of patients left before treatment - Sat 4*
No. of patients seen - Sat 4*
No. of patients with procedure - Sat 4*
No. of patients cancelled - Sat 4*
No. of new patients discharged - Sat 4*
No. of follow-ups discharged - Sat 4*
Total no. of patients discharged - Sat 4*
Saturday - Subspecialty 5 Room Number - Sat 5*
Subspecialty - Sat 5* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sat 5* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sat 5* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sat 5*
No. of new patients seen - Sat 5*
No. of follow-ups seen - Sat 5*
No. of patients DNA - Sat 5*
No. of patients left before treatment - Sat 5*
No. of patients seen - Sat 5*
No. of patients with procedure - Sat 5*
No. of patients cancelled - Sat 5*
No. of new patients discharged - Sat 5*
No. of follow-ups discharged - Sat 5*
Total no. of patients discharged - Sat 5*
Sunday - Subspecialty 1 Room Number - Sun 1*
Subspecialty - Sun 1* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sun 1* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sun 1* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sun 1*
No. of new patients seen - Sun 1*
No. of follow-ups seen - Sun 1*
No. of patients DNA - Sun 1*
No. of patients left before treatment - Sun 1*
No. of patients seen - Sun 1*
No. of patients with procedure - Sun 1*
No. of patients cancelled - Sun 1*
No. of new patients discharged - Sun 1*
No. of follow-ups discharged - Sun 1*
Total no. of patients discharged - Sun 1*
Sunday - Subspecialty 2 Room Number - Sun 2*
Subspecialty - Sun 2* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sun 2* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sun 2* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sun 2*
No. of new patients seen - Sun 2*
No. of follow-ups seen - Sun 2*
No. of patients DNA - Sun 2*
No. of patients left before treatment - Sun 2*
No. of patients seen - Sun 2*
No. of patients with procedure - Sun 2*
No. of patients cancelled - Sun 2*
No. of new patients discharged - Sun 2*
No. of follow-ups discharged - Sun 2*
Total no. of patients discharged - Sun 2*
Sunday - Subspecialty 3 Room Number - Sun 3*
Subspecialty - Sun 3* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sun 3* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sun 3* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sun 3*
No. of new patients seen - Sun 3*
No. of follow-ups seen - Sun 3*
No. of patients DNA - Sun 3*
No. of patients left before treatment - Sun 3*
No. of patients seen - Sun 3*
No. of patients with procedure - Sun 3*
No. of patients cancelled - Sun 3*
No. of new patients discharged - Sun 3*
No. of follow-ups discharged - Sun 3*
Total no. of patients discharged - Sun 3*
Sunday - Subspecialty 4 Room Number - Sun 4*
Subspecialty - Sun 4* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sun 4* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sun 4* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sun 4*
No. of new patients seen - Sun 4*
No. of follow-ups seen - Sun 4*
No. of patients DNA - Sun 4*
No. of patients left before treatment - Sun 4*
No. of patients seen - Sun 4*
No. of patients with procedure - Sun 4*
No. of patients cancelled - Sun 4*
No. of new patients discharged - Sun 4*
No. of follow-ups discharged - Sun 4*
Total no. of patients discharged - Sun 4*
Sunday - Subspecialty 5 Room Number - Sun 5*
Subspecialty - Sun 5* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Sun 5* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Sun 5* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Sun 5*
No. of new patients seen - Sun 5*
No. of follow-ups seen - Sun 5*
No. of patients DNA - Sun 5*
No. of patients left before treatment - Sun 5*
No. of patients seen - Sun 5*
No. of patients with procedure - Sun 5*
No. of patients cancelled - Sun 5*
No. of new patients discharged - Sun 5*
No. of follow-ups discharged - Sun 5*
Total no. of patients discharged - Sun 5*
Monday - Subspecialty 1 Room Number - Mon 1*
Subspecialty - Mon 1* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Mon 1* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Mon 1* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Mon 1*
No. of new patients seen - Mon 1*
No. of follow-ups seen - Mon 1*
No. of patients DNA - Mon 1*
No. of patients left before treatment - Mon 1*
No. of patients seen - Mon 1*
No. of patients with procedure - Mon 1*
No. of patients cancelled - Mon 1*
No. of new patients discharged - Mon 1*
No. of follow-ups discharged - Mon 1*
Total no. of patients discharged - Mon 1*
Monday - Subspecialty 2 Room Number - Mon 2*
Subspecialty - Mon 2* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Mon 2* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Mon 2* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Mon 2*
No. of new patients seen - Mon 2*
No. of follow-ups seen - Mon 2*
No. of patients DNA - Mon 2*
No. of patients left before treatment - Mon 2*
No. of patients seen - Mon 2*
No. of patients with procedure - Mon 2*
No. of patients cancelled - Mon 2*
No. of new patients discharged - Mon 2*
No. of follow-ups discharged - Mon 2*
Total no. of patients discharged - Mon 2*
Monday - Subspecialty 3 Room Number - Mon 3*
Subspecialty - Mon 3* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Mon 3* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Mon 3* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Mon 3*
No. of new patients seen - Mon 3*
No. of follow-ups seen - Mon 3*
No. of patients DNA - Mon 3*
No. of patients left before treatment - Mon 3*
No. of patients seen - Mon 3*
No. of patients with procedure - Mon 3*
No. of patients cancelled - Mon 3*
No. of new patients discharged - Mon 3*
No. of follow-ups discharged - Mon 3*
Total no. of patients discharged - Mon 3*
Monday - Subspecialty 4 Room Number - Mon 4*
Subspecialty - Mon 4* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Mon 4* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Mon 4* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Mon 4*
No. of new patients seen - Mon 4*
No. of follow-ups seen - Mon 4*
No. of patients DNA - Mon 4*
No. of patients left before treatment - Mon 4*
No. of patients seen - Mon 4*
No. of patients with procedure - Mon 4*
No. of patients cancelled - Mon 4*
No. of new patients discharged - Mon 4*
No. of follow-ups discharged - Mon 4*
Total no. of patients discharged - Mon 4*
Monday - Subspecialty 5 Room Number - Mon 5*
Subspecialty - Mon 5* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Mon 5* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Mon 5* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Mon 5*
No. of new patients seen - Mon 5*
No. of follow-ups seen - Mon 5*
No. of patients DNA - Mon 5*
No. of patients left before treatment - Mon 5*
No. of patients seen - Mon 5*
No. of patients with procedure - Mon 5*
No. of patients cancelled - Mon 5*
No. of new patients discharged - Mon 5*
No. of follow-ups discharged - Mon 5*
Total no. of patients discharged - Mon 5*
Tuesday - Subspecialty 1 Room Number - Tue 1*
Subspecialty - Tue 1* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Tue 1* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Tue 1* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Tue 1*
No. of new patients seen - Tue 1*
No. of follow-ups seen - Tue 1*
No. of patients DNA - Tue 1*
No. of patients left before treatment - Tue 1*
No. of patients seen - Tue 1*
No. of patients with procedure - Tue 1*
No. of patients cancelled - Tue 1*
No. of new patients discharged - Tue 1*
No. of follow-ups discharged - Tue 1*
Total no. of patients discharged - Tue 1*
Tuesday - Subspecialty 2 Room Number - Tue 2*
Subspecialty - Tue 2* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Tue 2* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Tue 2* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Tue 2*
No. of new patients seen - Tue 2*
No. of follow-ups seen - Tue 2*
No. of patients DNA - Tue 2*
No. of patients left before treatment - Tue 2*
No. of patients seen - Tue 2*
No. of patients with procedure - Tue 2*
No. of patients cancelled - Tue 2*
No. of new patients discharged - Tue 2*
No. of follow-ups discharged - Tue 2*
Total no. of patients discharged - Tue 2*
Tuesday - Subspecialty 3 Room Number - Tue 3*
Subspecialty - Tue 3* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Tue 3* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Tue 3* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Tue 3*
No. of new patients seen - Tue 3*
No. of follow-ups seen - Tue 3*
No. of patients DNA - Tue 3*
No. of patients left before treatment - Tue 3*
No. of patients seen - Tue 3*
No. of patients with procedure - Tue 3*
No. of patients cancelled - Tue 3*
No. of new patients discharged - Tue 3*
No. of follow-ups discharged - Tue 3*
Total no. of patients discharged - Tue 3*
Tuesday - Subspecialty 4 Room Number - Tue 4*
Subspecialty - Tue 4* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Tue 4* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Tue 4* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Tue 4*
No. of new patients seen - Tue 4*
No. of follow-ups seen - Tue 4*
No. of patients DNA - Tue 4*
No. of patients left before treatment - Tue 4*
No. of patients seen - Tue 4*
No. of patients with procedure - Tue 4*
No. of patients cancelled - Tue 4*
No. of new patients discharged - Tue 4*
No. of follow-ups discharged - Tue 4*
Total no. of patients discharged - Tue 4*
Tuesday - Subspecialty 5 Room Number - Tue 5*
Subspecialty - Tue 5* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Tue 5* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Tue 5* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Tue 5*
No. of new patients seen - Tue 5*
No. of follow-ups seen - Tue 5*
No. of patients DNA - Tue 5*
No. of patients left before treatment - Tue 5*
No. of patients seen - Tue 5*
No. of patients with procedure - Tue 5*
No. of patients cancelled - Tue 5*
No. of new patients discharged - Tue 5*
No. of follow-ups discharged - Tue 5*
Total no. of patients discharged - Tue 5*
Wednesday - Subspecialty 1 Room Number - Wed 1*
Subspecialty - Wed 1* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Wed 1* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Wed 1* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Wed 1*
No. of new patients seen - Wed 1*
No. of follow-ups seen - Wed 1*
No. of patients DNA - Wed 1*
No. of patients left before treatment - Wed 1*
No. of patients seen - Wed 1*
No. of patients with procedure - Wed 1*
No. of patients cancelled - Wed 1*
No. of new patients discharged - Wed 1*
No. of follow-ups discharged - Wed 1*
Total no. of patients discharged - Wed 1*
Wednesday - Subspecialty 2 Room Number - Wed 2*
Subspecialty - Wed 2* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Wed 2* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Wed 2* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Wed 2*
No. of new patients seen - Wed 2*
No. of follow-ups seen - Wed 2*
No. of patients DNA - Wed 2*
No. of patients left before treatment - Wed 2*
No. of patients seen - Wed 2*
No. of patients with procedure - Wed 2*
No. of patients cancelled - Wed 2*
No. of new patients discharged - Wed 2*
No. of follow-ups discharged - Wed 2*
Total no. of patients discharged - Wed 2*
Wednesday - Subspecialty 3 Room Number - Wed 3*
Subspecialty - Wed 3* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Wed 3* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Wed 3* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Wed 3*
No. of new patients seen - Wed 3*
No. of follow-ups seen - Wed 3*
No. of patients DNA - Wed 3*
No. of patients left before treatment - Wed 3*
No. of patients seen - Wed 3*
No. of patients with procedure - Wed 3*
No. of patients cancelled - Wed 3*
No. of new patients discharged - Wed 3*
No. of follow-ups discharged - Wed 3*
Total no. of patients discharged - Wed 3*
Wednesday - Subspecialty 4 Room Number - Wed 4*
Subspecialty - Wed 4* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Wed 4* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Wed 4* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Wed 4*
No. of new patients seen - Wed 4*
No. of follow-ups seen - Wed 4*
No. of patients DNA - Wed 4*
No. of patients left before treatment - Wed 4*
No. of patients seen - Wed 4*
No. of patients with procedure - Wed 4*
No. of patients cancelled - Wed 4*
No. of new patients discharged - Wed 4*
No. of follow-ups discharged - Wed 4*
Total no. of patients discharged - Wed 4*
Wednesday - Subspecialty 5 Room Number - Wed 5*
Subspecialty - Wed 5* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Wed 5* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Wed 5* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Wed 5*
No. of new patients seen - Wed 5*
No. of follow-ups seen - Wed 5*
No. of patients DNA - Wed 5*
No. of patients left before treatment - Wed 5*
No. of patients seen - Wed 5*
No. of patients with procedure - Wed 5*
No. of patients cancelled - Wed 5*
No. of new patients discharged - Wed 5*
No. of follow-ups discharged - Wed 5*
Total no. of patients discharged - Wed 5*
Thursday - Subspecialty 1 Room Number - Thu 1*
Subspecialty - Thu 1* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Thu 1* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Thu 1* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Thu 1*
No. of new patients seen - Thu 1*
No. of follow-ups seen - Thu 1*
No. of patients DNA - Thu 1*
No. of patients left before treatment - Thu 1*
No. of patients seen - Thu 1*
No. of patients with procedure - Thu 1*
No. of patients cancelled - Thu 1*
No. of new patients discharged - Thu 1*
No. of follow-ups discharged - Thu 1*
Total no. of patients discharged - Thu 1*
Thursday - Subspecialty 2 Room Number - Thu 2*
Subspecialty - Thu 2* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Thu 2* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Thu 2* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Thu 2*
No. of new patients seen - Thu 2*
No. of follow-ups seen - Thu 2*
No. of patients DNA - Thu 2*
No. of patients left before treatment - Thu 2*
No. of patients seen - Thu 2*
No. of patients with procedure - Thu 2*
No. of patients cancelled - Thu 2*
No. of new patients discharged - Thu 2*
No. of follow-ups discharged - Thu 2*
Total no. of patients discharged - Thu 2*
Thursday - Subspecialty 3 Room Number - Thu 3*
Subspecialty - Thu 3* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Thu 3* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Thu 3* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Thu 3*
No. of new patients seen - Thu 3*
No. of follow-ups seen - Thu 3*
No. of patients DNA - Thu 3*
No. of patients left before treatment - Thu 3*
No. of patients seen - Thu 3*
No. of patients with procedure - Thu 3*
No. of patients cancelled - Thu 3*
No. of new patients discharged - Thu 3*
No. of follow-ups discharged - Thu 3*
Total no. of patients discharged - Thu 3*
Thursday - Subspecialty 4 Room Number - Thu 4*
Subspecialty - Thu 4* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Thu 4* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Thu 4* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Thu 4*
No. of new patients seen - Thu 4*
No. of follow-ups seen - Thu 4*
No. of patients DNA - Thu 4*
No. of patients left before treatment - Thu 4*
No. of patients seen - Thu 4*
No. of patients with procedure - Thu 4*
No. of patients cancelled - Thu 4*
No. of new patients discharged - Thu 4*
No. of follow-ups discharged - Thu 4*
Total no. of patients discharged - Thu 4*
Thursday - Subspecialty 5 Room Number - Thu 5*
Subspecialty - Thu 5* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Thu 5* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Thu 5* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Thu 5*
No. of new patients seen - Thu 5*
No. of follow-ups seen - Thu 5*
No. of patients DNA - Thu 5*
No. of patients left before treatment - Thu 5*
No. of patients seen - Thu 5*
No. of patients with procedure - Thu 5*
No. of patients cancelled - Thu 5*
No. of new patients discharged - Thu 5*
No. of follow-ups discharged - Thu 5*
Total no. of patients discharged - Thu 5*
Friday - Subspecialty 1 Room Number - Fri 1*
Subspecialty - Fri 1* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Fri 1* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Fri 1* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Fri 1*
No. of new patients seen - Fri 1*
No. of follow-ups seen - Fri 1*
No. of patients DNA - Fri 1*
No. of patients left before treatment - Fri 1*
No. of patients seen - Fri 1*
No. of patients with procedure - Fri 1*
No. of patients cancelled - Fri 1*
No. of new patients discharged - Fri 1*
No. of follow-ups discharged - Fri 1*
Total no. of patients discharged - Fri 1*
Friday - Subspecialty 2 Room Number - Fri 2*
Subspecialty - Fri 2* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Fri 2* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Fri 2* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Fri 2*
No. of new patients seen - Fri 2*
No. of follow-ups seen - Fri 2*
No. of patients DNA - Fri 2*
No. of patients left before treatment - Fri 2*
No. of patients seen - Fri 2*
No. of patients with procedure - Fri 2*
No. of patients cancelled - Fri 2*
No. of new patients discharged - Fri 2*
No. of follow-ups discharged - Fri 2*
Total no. of patients discharged - Fri 2*
Friday - Subspecialty 3 Room Number - Fri 3*
Subspecialty - Fri 3* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Fri 3* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Fri 3* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Fri 3*
No. of new patients seen - Fri 3*
No. of follow-ups seen - Fri 3*
No. of patients DNA - Fri 3*
No. of patients left before treatment - Fri 3*
No. of patients seen - Fri 3*
No. of patients with procedure - Fri 3*
No. of patients cancelled - Fri 3*
No. of new patients discharged - Fri 3*
No. of follow-ups discharged - Fri 3*
Total no. of patients discharged - Fri 3*
Friday - Subspecialty 4 Room Number - Fri 4*
Subspecialty - Fri 4* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Fri 4* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Fri 4* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Fri 4*
No. of new patients seen - Fri 4*
No. of follow-ups seen - Fri 4*
No. of patients DNA - Fri 4*
No. of patients left before treatment - Fri 4*
No. of patients seen - Fri 4*
No. of patients with procedure - Fri 4*
No. of patients cancelled - Fri 4*
No. of new patients discharged - Fri 4*
No. of follow-ups discharged - Fri 4*
Total no. of patients discharged - Fri 4*
Friday - Subspecialty 5 Room Number - Fri 5*
Subspecialty - Fri 5* -- Please select -- General Glaucoma Hydroxychloroquine Intravitreal Injection Laser Medical Retina Occuloplastics Post-operative Pre-assessment
Start time of first patient Consultation - Fri 5* This is the time the first patient enters the consultation/clinic room
End time of last patient consultation - Fri 5* This is the time the last patient leaves the consultation/clinic room. Please exclude recovery time etc.
No. of patients booked - Fri 5*
No. of new patients seen - Fri 5*
No. of follow-ups seen - Fri 5*
No. of patients DNA - Fri 5*
No. of patients left before treatment - Fri 5*
No. of patients seen - Fri 5*
No. of patients with procedure - Fri 5*
No. of patients cancelled - Fri 5*
No. of new patients discharged - Fri 5*
No. of follow-ups discharged - Fri 5*
Total no. of patients discharged - Fri 5*
Ophthalmology Specific Data Ophthalmology Specific Data - Saturday New OCTs - Sat*
Follow-up OCTs - Sat*
Lasers - Sat*
Injections - Sat*
Minor Ops - Sat*
Visual Fields - Sat*
FFA - Sat*
Auto Fluorescence - Sat*
Pre-Assessment - Sat*
Pentacam - Sat*
Colours - Sat*
Phasing - Sat*
Ophthalmology Specific Data - Sunday New OCTs - Sun*
Follow-up OCTs - Sun*
Lasers - Sun*
Injections - Sun*
Minor Ops - Sun*
Visual Fields - Sun*
FFA - Sun*
Auto Fluorescence - Sun*
Pre-Assessment - Sun*
Pentacam - Sun*
Colours - Sun*
Phasing - Sun*
Ophthalmology Specific Data - Monday New OCTs - Mon*
Follow-up OCTs - Mon*
Lasers - Mon*
Injections - Mon*
Minor Ops - Mon*
Visual Fields - Mon*
FFA - Mon*
Auto Fluorescence - Mon*
Pre-Assessment - Mon*
Pentacam - Mon*
Colours - Mon*
Phasing - Mon*
Ophthalmology Specific Data - Tuesday New OCTs - Tue*
Follow-up OCTs - Tue*
Lasers - Tue*
Injections - Tue*
Minor Ops - Tue*
Visual Fields - Tue*
FFA - Tue*
Auto Fluorescence - Tue*
Pre-Assessment - Tue*
Pentacam - Tue*
Colours - Tue*
Phasing - Tue*
Ophthalmology Specific Data - Wednesday New OCTs - Wed*
Follow-up OCTs - Wed*
Lasers - Wed*
Injections - Wed*
Minor Ops - Wed*
Visual Fields - Wed*
FFA - Wed*
Auto Fluorescence - Wed*
Pre-Assessment - Wed*
Pentacam - Wed*
Colours - Wed*
Phasing - Wed*
Ophthalmology Specific Data - Thursday New OCTs - Thu*
Follow-up OCTs - Thu*
Lasers - Thu*
Injections - Thu*
Minor Ops - Thu*
Visual Fields - Thu*
FFA - Thu*
Auto Fluorescence - Thu*
Pre-Assessment - Thu*
Pentacam - Thu*
Colours - Thu*
Phasing - Thu*
Ophthalmology Specific Data - Friday New OCTs - Fri*
Follow-up OCTs - Fri*
Lasers - Fri*
Injections - Fri*
Minor Ops - Fri*
Visual Fields - Fri*
FFA - Fri*
Auto Fluorescence - Fri*
Pre-Assessment - Fri*
Pentacam - Fri*
Colours - Fri*
Phasing - Fri*
Cancellations
Please accurately record reasons for patients being cancelled. If patients are cancelled for clinical reasons, this should be captured on the patient cancellation outcome form which must be signed by the relevant doctor.
Cancellations
Safety
Clinical Induction
It is the responsibility of the Nurse in Charge to ensure that all 18 Week Support staff are orientated to the clinical environment and are clear on the clinical pathways for the service.
Pre-list briefing and staff allocation undertaken* For all days worked
If No, please state the reason why
Patient Journey and Referral pathway demonstrated to staff* For all days worked
If No, please state the reason why
Incidents, Near Misses and Complaints Any incidents or near misses to report?* Incidents/Near Misses
This needs to be filled in if there have been any Adverse Incidents/ complications/Serious Incidents/Never Events. All incidents must be reported onto the 18WS Datix system
Patient Complaints or Potential Complaints
Anything you think may need to be followed up with the Trust
Patient Satisfaction
Have the patient satisfaction surveys been collected and posted from your site?
Sat* How many forms were collected? - Sat*
If No, please state the reason why - Sat*
Sun* How many forms were collected? - Sun*
If No, please state the reason why - Sun*
Mon* How many forms were collected? - Mon*
If No, please state the reason why - Mon*
Tues* How many forms were collected? - Tues*
If No, please state the reason why - Tues*
Wed* How many forms were collected? - Wed*
If No, please state the reason why - Wed*
Thu* How many forms were collected? - Thu*
If No, please state the reason why - Thu*
Fri* How many forms were collected? - Fri*
If No, please state the reason why - Fri*
Patients of Concern Have the Patient of Concern Forms been completed and submitted? If there are no patients of concern, please state reason.* If No, please state reason why*
Quality Assurance
Clinical Administration Breaking bad news-patients informed regarding potential malignancy* For all days worked
If No, please state reason why*
Any new cancers found?* Patient details
All referrals, follow up tests , MDT paperwork completed.* Please ensure that you have used the correct Trust proformas to organise anything required for ongoing
care ,so as to avoid delays
* For all days worked
If No, please state reason why*
All specimens are correctly labeled checked with the Trust link nurse and processed.* All specimens need to be checked prior to the patient leave the clinical area. Specimens should be labeled accordingly, documented correctly in the medical records and specimen request form.
If No, please state reason why*
Patient outcomes sheet completed and agreed by doctor and coordinator* Within each speciality for every pateint seen we require a clinical outcome which provides an audit trail of our interaction with patient i.e procedure/test/investigations etc.
If No, please state reason why*
Trust Environment Have you restocked all clinical areas?* If No, please state reason why*
Have you cleaned all clinical areas?* If No, please state reason why*
Have you checked all clinical equipment?* If No, please state reason why*
Were there any issues with the equipment prior to the NIC leaving the unit? If yes, please report as incident.* If yes please explain?*
Resus Trolleys - Saturday How many Resus Trolleys are on site? - Sat* -- Please select -- 0 1 2 3
Location* Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?* Was the emergency alerting system checked?* Was the check documented?* By whom* Name - Trust staff*
Name - 18WS Staff*
Name - NIC*
If No* -- Please select - No Resus Trolley available Trust staff responsibility Checked by trust staff Check not required Only checked once a week Not applicable
Action taken* -- Please select - No action required Link Nurse informed Fed back to trust team Other
Other*
Resus Trolleys - Sunday How many Resus Trolleys are on site? - Sun* -- Please select -- 0 1 2 3
Location* Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?* Was the emergency alerting system checked?* Was the check documented?* By whom* Name - Trust staff*
Name - 18WS staff*
Name - NIC*
If No* -- Please select - No Resus Trolley available Trust staff responsibility Checked by trust staff Check not required Only checked once a week Not applicable
Action taken* -- Please select - No action required Link Nurse informed Fed back to trust team Other
Other*
Resus Trolleys - Monday How many Resus Trolleys are on site? - Mon* -- Please select -- 0 1 2 3
Location* Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?* Was the emergency alerting system checked?* Was the check documented?* By whom* Name - Trust staff*
Name - 18WS staff*
Name - NIC*
If No* -- Please select - No Resus Trolley available Trust staff responsibility Checked by trust staff Check not required Only checked once a week Not applicable
Action taken* -- Please select - No action required Link Nurse informed Fed back to trust team Other
Other*
Resus Trolleys - Tuesday How many Resus Trolleys are on site? - Tues* -- Please select -- 0 1 2 3
Location* Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?* Was the emergency alerting system checked?* Was the check documented?* By whom* Name - Trust staff*
Name - 18WS staff*
Name - NIC*
If No* -- Please select - No Resus Trolley available Trust staff responsibility Checked by trust staff Check not required Only checked once a week Not applicable
Action taken* -- Please select - No action required Link Nurse informed Fed back to trust team Other
Other*
Resus Trolleys - Wednesday How many Resus Trolleys are on site? - Wed* -- Please select -- 0 1 2 3
Location* Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?* Was the emergency alerting system checked?* Was the check documented?* By whom* Name - Trust staff*
Name - 18WS staff*
Name - NIC*
If No* -- Please select - No Resus Trolley available Trust staff responsibility Checked by trust staff Check not required Only checked once a week Not applicable
Action taken* -- Please select - No action required Link Nurse informed Fed back to trust team Other
Other*
Resus Trolleys - Thursday How many Resus Trolleys are on site? - Thu* -- Please select -- 0 1 2 3
Location* Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?* Was the emergency alerting system checked?* Was the check documented?* By whom* Name - Trust staff*
Name - 18WS staff*
Name - NIC*
If No* -- Please select - No Resus Trolley available Trust staff responsibility Checked by trust staff Check not required Only checked once a week Not applicable
Action taken* -- Please select - No action required Link Nurse informed Fed back to trust team Other
Other
Resus Trolleys - Friday How many Resus Trolleys are on site? - Fri* -- Please select -- 0 1 2 3
Location* Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?* Was the emergency alerting system checked?* Was the check documented?* By whom* Name - Trust staff*
Name - 18WS staff*
Name - NIC*
If No* -- Please select - No Resus Trolley available Trust staff responsibility Checked by trust staff Check not required Only checked once a week Not applicable
Action taken* -- Please select - No action required Link Nurse informed Fed back to trust team Other
Other*
Is the Trust link nurse or NIC happy with all the above checks?* Operational Issues 18 Week Support Operational Issues
Staff issues with accommodation and travel
Trust Operational Issues
Any other comments?
Signature* Date Completed*
DD slash MM slash YYYY
Email*
Please use your NHS.net or 18weeksupport.com address.
