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15235 Shady Grove Road, Suite 102, Rockville, MD 20850 Phone: (301) 330-9430 Fax: (301) 330-6515 www.ohpmd.com Name: _________________________________________ DOB: _____________ Date: _________________ IV antibiotics are given only when the severity of the condition warrants the risk-benefit considerations of intravenous access catheters and medications. These risks include but are not limited to severe infection related to the catheter, allergic or other reactions or dependencies on the intravenous drugs, and clot formation around the catheter with a risk of embolism to the lung or brain with resulting stroke. Therefore, we consider IV antibiotics a serious medical intervention to be undertaken only after careful consideration of all other contributing factors and other possible diagnoses. An effective course of IV antibiotics may last from three to six months. Given the severity of your medical condition, you and our medical staff have determined that intravenous antibiotics are appropriate at this time. We would now like to summarize the basis for treatment, familiarize you with the process, our related procedures, and inform you of our fees for this service. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ (1) Patient must arrange schedule and location for insertion ii) First dose of antibiotic to be administered when PICC line is placed i) PICC line care, patient instruction ii) Prescriptions for ongoing supply of appropriate intravenous antibiotics and medications iii) Weekly PICC line site check and dressing change 2) The home health agency will arrange with you to start home therapy. 3) The home health agency will instruct you on how to administer antibiotics and care for your PICC line. 4) The home health agency will examine your catheter site regularly, change the dressing, and arrange for weekly blood drawing to monitor for potential side effects. 5) OHP will monitor lab results weekly. 6) OHP will schedule follow-up telephone consultations (typically at week three and week nine) to review your treatment and adjusts therapy as needed. There is no additional charge for these phone consults. 7) OHP will schedule you for a 45-minute office visit at approximately week six of your treatment. IV Antibiotic Patient Forms 20101229.doc 15235 Shady Grove Road, Suite 102, Rockville, MD 20850 Phone: (301) 330-9430 Fax: (301) 330-6515 www.ohpmd.com Typical Fees for a Three-Month Treatment Cycle 1) Initial medical documentation and administrative set up with home health agency: $200 a) Administrative coordination with home health agency and form completion b) Weekly physician review of laboratory tests c) Alternating three-week telephone consultations and office visits (see chart below) d) The cycle shown in the chart below simply extends as needed for therapy lasting more than 12 weeks I have read the above, have had a chance to consider this information carefully, and have had the chance to ask questions and receive answers that I understand. _____________________________________________________ _______________ Patient _____________________________________________________ _______________ Physician Signature IV Antibiotic Patient Forms 20101229.doc 15235 Shady Grove Road, Suite 102, Rockville, MD 20850 Phone: (301) 330-9430 Fax: (301) 330-6515 www.ohpmd.com Informed Consent for Intravenous Antibiotic Treatment Name: _____________________________________ DOB: _____________ Date: _________________ IV antibiotics are given only when the severity of the condition warrants the risk-benefit considerations of intravenous access catheters and medications. These risks include but are not limited to severe infection related to the catheter, allergic or other reactions or dependencies on the intravenous drugs, and clot formation around the catheter with a risk of embolism to the lung or brain with resulting stroke. Therefore, we consider IV antibiotics a serious medical intervention to be undertaken only after careful consideration of all other contributing factors and other possible diagnoses. In certain situations, intravenous (IV) medications are preferred or may be used to supplement oral medications. IV treatment is sometimes recommended when there is neurological involvement, heart problems, severe joint inflammation, or inadequate response to oral medications. Because the GI system is bypassed, IV dosing greatly increases the probability of adequate medication blood levels and reduces gastrointestinal symptoms. IV antibiotics also may penetrate the blood brain barrier more effectively. There are additional risks associated with IV treatment. IV treatment usually involves the installation of an intravenous line in my vein to allow easier IV treatment. PICC lines may result in local infection, or if unchecked, systemic infection. If signs of skin inflammation occur, the line may need to be removed. Rarely, PICC lines break off when they are being removed and may then require surgical removal. There is also a chance that, upon insertion, a nerve near the vein could be damaged. There is a risk of blood clots from PICC line insertion. If a clot forms, the PICC line may be removed and I may be hospitalized for the initiation of anti-coagulation therapy. The risk of clot development is decreased, although not eliminated, by flushing the PICC line twice daily with saline and heparin and by avoiding vigorous repetitive motion activity of the arm in which the PICC line is placed. The major side effects of antibiotics include rash, diarrhea, changes in liver function or blood counts, and in some cases, gall bladder disease. [The OHP protocol includes prescribing Actigall as a preventative measure for gall bladder disease.] These symptoms usually resolve after the medication is stopped, however, the reactions can be very severe and may require treatment including hospitalization. It is important to notify our office and also the infusion / home health agency as soon as you become aware of any problem or if you have any concern or question. _______________________________________________________________________________________________ My questions have all been answered in terms I understand. I am aware of the risks in foregoing IV treatment as well as the potential side effects if I undergo this treatment, and I consent to the use of IV treatment. ____________________________________________ ________________________________ Patient ____________________________________________ _________________________________ Print IV Antibiotic Patient Forms 20101229.doc

Source: http://www.ohpmd.com/images/IV_Antibiotic_Patient_Forms_20101229.pdf

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