Adding Data to the Key Information Summary

Adding, editing and viewing data in the KIS screen is easy. There is a combination of tick boxes (see Tick Boxes) and data entry panes (see Data Entry Panes) for the following information:

Note - Categories with an asterisk* are shared with the Palliative Care Summary screen

  • Capacity information and Care Plan Details – Displays and allows you to record the following:
    • Has Guardianship Order – 918S.00 Legal guardian details
    • Has Power of Attorney –
    • 9W6..00 Enduring power of attorney
    • Has Adult Incapacity Form – This is free text and displays as a Notepad entry
    • Has Single Shared Assessment Plan – select from:
    • 9Ne..00 Single Assessment Process
    • 9Ne0.00 Single assessment process summary care plan completed
    • Has Anticipatory Care Plan – 8CMM.00 Has anticipatory care plan
    • Advanced Decision to Refuse Treatment - select from:
    • 9NqzJ00 Advance decision to refuse treatment retracted
    • 9X2..00 Advanced directive signed
    • 9X2..11 Advance decision signed
    • 9X2..12 Advance directive signed
    • 9X20.00 Advanced directive signed (copy in notes)
    • 9X220.11 Advance directive signed (copy in notes)
    • Record NI Cancer Registry Consent Status - Notepad entry, select from:
    • Not known
    • Not applicable
    • Consent to participate
    • Dissent to participate
  • Self-Management Plan details – Displays and allows you to record the following Read codes and any relevant free text comments:
    • 661M. Clinical management plan agreed
    • 661M0 Angina self-management plan agreed
    • 661M1 Asthma self-management plan agreed
    • 661M2 Chronic kidney disease self-management plan agreed
    • 661M3 Chronic obstructive pulmonary disease self-management plan agreed
    • 661M4 Diabetes self-management plan agreed
    • 661M5 Heart failure self-management plan agreed
    • 661M6 Hypertension self-management plan agreed
    • 661M7 Stroke self-management plan agreed
    • 661N Clinical management plan review
    • 661N0 Angina self-management plan review
    • 661N1 Asthma self-management plan review
    • 661N2 Chronic kidney disease self-management plan review
    • 661N3 Chronic obstructive pulmonary disease self-management plan review
    • 661N4 Diabetes self-management plan review
    • 661N5 Heart failure self-management plan review
    • 661N6 Hypertension self-management plan review
    • 661N7 Stroke self-management plan review
    • 8BC1 Treatment plan given
    • 8CAs Advised to self care
    • 8CG6 Care programme approach review
    • 8CG600 Initial Care Programme Approach review]
    • 8CG60011 Initial CPA review
    • 8CG61 Ongoing care programme approach review
    • 8CG6111 Ongoing CPA review
    • 8CG62 Discharge care programme approach
    • 8CG6211 Discharge CPA review
    • 8CMA000 Patient has a written asthma personal plan
    • 8CMC Review of personal care plan
    • 8CMD Personal care plan completed
    • 8CMG1 Review of mental health care plan
    • 8CMY Has self management plan
    • 8CR Clinical management plan
    • 8CR0 Asthma clinical management plan
    • 8CR1 Chronic obstructive pulmonary disease clinical management plan
    • 8CR2 Diabetes clinical management plan
    • 8CR3 Hyperlipidaemia clinical management plan
    • 8CR4 Hypertension clinical management plan
    • 8CR5 Hypothyroidism clinical management plan
    • 8CR6 Coronary heart disease risk clinical management plan
    • 8CR7 Mental health personal health plan
    • 8CR9 Benzodiazepine clinical management plan
    • 8CRA Ankle brachial pressure index management plan
    • 8CRB Transient ischaemic attack clinical management plan
  • Other Care Plans - Displays and allows you to record the following Read codes and any relevant free text comments:
    • 69D9.00 Frail elderly assessment
    • 8CM Care plan
    • 8CMG.00 Review of care plan
    • 8CMW.00 Following clinical pathway protocol
    • 8CMW.11 Following clinical care pathway
    • 8CMW500 Chronic obstructive pulmonary disease care pathway
    • 8CMW700 Diabetes clinical pathway
    • 8CMW800 Heart failure clinical pathway
    • 8CMZ.00 Dementia care plan
    • 8CS Agreement of care plan - selecting Agreement of care plan automatically launches the Palliative Care Plan screen, see Recording an Initial Palliative Care Plan
    • 8CS0 Diabetes care plan agreed
    • 8CS1 Multiple sclerosis care plan agreed
    • 8CS2 Health and social care plan agreed
    • 8CS3 Agreeing on leg ulcer treatment plan
    • 8CS5 Agreeing on health professional actions in care plan
    • 8CS6 Agreeing on patient actions in care plan
    • 8CS7 Agreeing on mental health care plan
    • 8CS8 Agreeing on care plan with legitimate patient representative
    • 8CY Mental Health Care Programme Approach
    • 9HC2 Substance misuse clinical management plan agreed
    • 9HC3 Substance misuse clinical management plan reviewed
  • Patient Contact List* - Displays all latest contacts for the patient and allows you to add new contact details. These details are from Registration contacts. Carer, Next of Kin and End of Life (EoL) Key Worker details can be recorded by selecting Add Key Worker . For information on how to add carer details see - Adding Contacts.
  • Relevant Medical History* - Displays all medical history records with a priority of 1 and allows you to add further medical histories. See Adding/Removing Items to/from Relevant Medical History
  • Access information* - Displays and allows you to record the following Read codes:
    • 9189 Key Holder
    • 9NFG Address instruction
    • 915L Patient door access key code
  • Other Agencies involved*– Displays and allows you to record the following Read codes:
    • 13G..00 Domiciliary services
    • 13G1.00 District nurse attends
    • 13G2.00 Health visitor visits
    • 13G5.00 Voluntary worker
    • 13G6100 Home help attends
    • 13G6300 Home help organised
    • 13G7.00 Meals on wheels
    • 13G8.00 Domiciliary chiropody
    • 13GZ.00 Domiciliary service NOS
    • 8HH0.00 Arrange care by relative
    • 8HH4.00 Arrange care attender
    • 8HH7.00 Referred to community specialist palliative care team
    • 8HHB.00 Referral to Social Services
    • 8HHJ.00 Referral to respiratory nurse specialist
    • 8HHN.00 Referral to voluntary service
    • 9N2i.00 Seen by diabetic liaison nurse
    • 9N2p.00 Seen by community heart failure nurse
    • 9NNA.00 Under care of practice nurse
    • 9NNK.00 Under care of dyspepsia specialist nurse
    • 9NNS.00 Under care of Macmillan nurse
    • 9NNY.00 Under multi-agency care
    • 9NNd.00 Under care of palliative care specialist nurse
    • 9Nh0.00 Under the care of community palliative care team
    • 9Nh1.00 Under care cancer primary healthcare multidisciplinary team
    • 9NIP.00 Seen by clinical nurse specialist
  • Special note* - Displays and allows you to submit additional free text information to assist OOH staff manage your patient's care. See Adding or Updating a Special Note
  • Other useful palliative information* - Displays and allows you to record the following:
    • Has DNACPR Form – enter free text as required. If a patient has a DNACPR Form, you should ensure the Resuscitation status that follows, matches. If you do not make this correction, the conflict is transferred to ECS.
      Important - Only the latest Resuscitation entry is sent.

    DNACPR Form and Resuscitation status examples

    Correct DNACPR Form and Resuscitation status

    Conflicting DNACPR and Resuscitation status

    Conflicting DNACPR and Resuscitation status

    • Resuscitation Status* – Defaults to Priority 1 select from:
    • 1R00.00 For attempted cardiopulmonary resuscitation
    • 1R10.00 Not for attempted CPR (cardiopulmonary resuscitation)
    • Resuscitation discussed with patient* - 67P0 Resuscitation discussed with patient
    • Resuscitation discussed with carer* - 67P1 Resuscitation discussed with carer
    • Has CYPADM form* - 8CMN.00 has children and young people acute deterioration management plan
    • Additional Drugs at Home* – enter free text as required
    • Catheter and Incontinence Equipment at Home* – select from:
    • 9NgX.00 Catheter care equipment available at home
    • 9NgY.00 Continence care equipment available at home

      Note - Both Catheter and Incontinence options can be selected, but only the latest entry displays.

    • Moving and Handling Equipment at Home* – 13CX.00 Moving and handling equipment available at home
    • Has Oxygen for Home Use – select from:
    • 6639.00 Home oxygen supply
    • 6639.11 Home oxygen supply started
    • 6639.12 Oxygen at home
    • 66Yj.00 Home oxygen supply – cylinder
    • 66Yk.00 Home oxygen supply – concentrator
    • 66YI.00 Home oxygen supply – liquid oxygen
    • 745E000 Home oxygen support
    • Has Advance Care Plan* - 8CME Has end of life advance care plan
    • Preferred Place of Care* – select from:
    • 8Ce..00 Preferred place of care
    • 8Ce0.00 Preferred place of care – home
    • 8Ce1.00 Preferred place of care – hospice
    • 8Ce2.00 Preferred place of care – community hospital
    • 8Ce3.00 Preferred place of care – hospital
    • 8Ce4.00 Preferred place of care – nursing home
    • 8Ce5.00 Preferred place of care – residential home
    • 8Ce5.11 Preferred place of care - care home
    • 8Ce6.00 Preferred place of care – learning disability unit
    • 8Ce7.00 Preferred place of care – mental health unit
    • 8Ce8.00 Preferred place of care – discussed with patient
    • 8Ce9.00 Preferred place of care – discussed with family
    • 8CeA.00 Preferred place of care – patient unable to express preference
    • 8CeB.00 Preferred place of care – patient declined to participate
    • 8CeC.00 Preferred place of care for next exacerbation heart failure
    • 8CeD.00 Preferred place of care for next exacerbation of COPD
    • 8CeE.00 Preferred place of care – discussion not appropriate
    • 8CeF.00 Preferred place of care - relative's home
    • 8CeG.00 Preferred place of care - patient undecided
    • Preferred Place of Final Care* – select from:
    • 94Z0.00 Preferred place of death
    • 94Z1.00 Preferred place of death: home
    • 94Z2.00 Preferred place of death: hospice
    • 94Z3.00 Preferred place of death: community hospital
    • 94Z4.00 Preferred place of death: hospital
    • 94Z5.00 Preferred place of death: nursing home
    • 94Z7.00 Preferred place of death: discussion not appropriate
    • 94Z8.00 Preferred place of death: patient undecided
    • 94ZB.00 Preferred place of death: discussed with family

      Note - Patient Preferred place of Final Care allows multiple entries. The latest active entry displays on the NI KIS screen, previous entries are displayed in the journal. You can mark entries as no longer active, only active entries are transmitted in the NI KIS message.

    • Willingness to issue death certificate out of hours* - Notepad entry, select from:
    • Yes/No
    • Issuing GP
    • Expiry date and notes

*those with an asterisk are shared with the PCS screen

Note - Data added here cannot be deleted here. If you need to delete data added here, it must be deleted from the patient's Journal screen in the usual way.

In this section

Tick Boxes

Data Entry Panes