Download USE ORIGINAL CHARTS ONLY

Bone Morphogenetic Protein Prescription Chart
for use in Orthopaedics and Neurosurgery
Allergies and Adverse Drug Reactions – List the medicines or
substances & the nature of the reaction (write NKDA if none)
It is mandatory to complete this section
Medicine / Substance
First Name:
Surname:
Hospital No:
Reaction
DOB:
NHS No:
Sample only - not
for clinical use
Sign (NAME)
Date
Sign (NAME)
Allergy status unconfirmed.
Authority to administer medicines
ceases after 24 hours.
Consultant:
Theatre
Hospital:
Time & Date
USE ORIGINAL CHARTS ONLY - DO NOT PHOTOCOPY
Has patient previously been given bone morphogenetic protein?
Y
/
N
PRESCRIPTION
Date
required
Drug
(Please delete one not required)
Eptotermin alfa
BMP7
Osigraft®
Eptotermin alfa
BMP7
Opgenra®
Dibotermin alfa
BMP2
Inductos®
Signature
ADMINISTRATION
Prescriber
(Consultant only)
Pharm
Batch
number/
sticker
Administered by:
Signature
Signature
PRINT name & contact details
PRINT name & contact details
Witness
PRINT name & contact details
Signature
Signature
PRINT name & contact details
PRINT name & contact details
Witness
PRINT name & contact details
Signature
Signature
PRINT name & contact details
PRINT name & contact details
Witness
PRINT name & contact details
Licensed indications
Eptotermin alfa
Osigraft - Treatment of non-union of tibia of at least 9 months duration, secondary to trauma, in skeletally mature patients, in cases
where previous treatment with autograft has failed or use of autograft is unfeasible.
Opgenra - Posterior lateral infusion
Dibotermin alfa
1. As a substitute for autogenous bone graft in adults requiring single level (L4-S1) anterior lumbar spine fusion for degenerative
disc disease, who had have at least 6 months non-operative treatment (licensed Indicator).
2. Treatment of acute tibia fractures in adults, as an adjunct to standard care using open reduction and intramedullary nail
fixation.
Instructions
1. This prescription should be sent to Advanced Clinical Pharmacist (ACP) for Orthopaedics/Neurosurgery at least 2 full working
days before it is required.
2. Vials must only be used for the named patient, any unused vials MUST be returned to Pharmacy immediately the operation is
concluded.
3. Please document the batch numbers of the vials used on this chart and ensure the chart is filed in the patients’ notes.
Pharmacy Staff
Please send this chart with the order to the relevant theatre.
If the Advanced Clinical Pharmacist (ACP) for Orthopaedics/Neurosurgery is unavailable, please supply the requested item and
leave a copy of the prescription request for the attention of the ACP.
Registered by Medicines Risk Management Group
Reviewed & re-registered
Next review
Pharm Ref No.
June 2011
March 2014
March 2016
11/006 v3
For further supplies please contact your
Ward Pharmacist.