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IMPLANT TRACKING CHART (Below is a sample chart)
| Patient Name:________ |
Date of Implant:________ |
Reservoir size:___________ |
| Patient ID#: _________ |
Pump model #: ________ |
Catheter length: __________ |
| Adm. date: __________ |
Catheter access port?___ |
Calibration constant: ______ |
| Date/Time |
Expected
Residual Volume |
Actual
Residual Volume |
Resevoir
Volume % Error |
Fill
Volume |
Drug
Concentration |
Daily
Dose |
Next
Refill Date |
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WARNING: DO NOT FILL THE PUMP WITH A DRUG CONCENTRATION
THAT EXCEEDS 10 TIMES THE DAILY DOSE
For any questions or concerns, call your
home IV nurse according to the instructions your nurse has given
you. Horizon Healthcare Services can also be reached 24 hours a
day at (717) 544-3590 or toll free at (800) 848-3204
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