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Adding Data to the Palliative Care Summary
Adding, editing and viewing data in the Palliative Care Summary screen is easy. There is a combination of tick boxes and data entry panes for the following information:
Note - Categories with an asterisk* are shared with the KIS screen
- Initial Palliative Care Plan – Displays and allows you to record the initial details of the Palliative Care Plan. See Recording an Initial Palliative Care Plan.
- Palliative Care Register (Qualifying Terms) - Displays and allows you to record the following Read codes:
- 1Z01.00 Terminal illness – late stage
- 8BA2.00 Terminal care
- 8BA2.11 End of life care
- 8BAP.00 Specialist palliative care
- 8BAR.00 Specialist care treatment - inpatient
- 8BAS.00 Specialist care treatment – daycare
- 8BAT.00 Specialist care treatment – outpatient
- 8BJ1.00 Palliative treatment
- 8CM1.00 On gold standards palliative care framework
- 8CM1500 GSF prognostic indicator stage A (blue) - yr plus prognosis
- 8CM1600 GSF prognostic indicator stage B (green) - months prognosis
- 8CM1700 GSF prognostic indicator stage C (yellow) - weeks prognosis
- 8CM1800 GSF prognostic indicator stage D (red) - days prognosis
- 8H6A.00 Refer to terminal care consultant
- 8H7L.00 Refer for terminal care
- 8H7g.00 Referral to palliative care service
- 8HH7.00 Referred to community specialist palliative care team
- 9367.00 Patient held palliative care record
- 9EB5.00 DS 1500 Disability living allowance completed
- 9Nh0.00 Under the care of the community palliative care team
- ZV57C00 [V]Palliative care
- Awareness and Understanding
- 1H...00 Awareness of diagnosis
- 1H0..00 Patient aware of diagnosis
- 1H0..11 Diagnosis known to patient
- 1H1.00 Patient not aware of diagnosis
- 1H2..00 Family aware of diagnosis
- 1H3..00 Family not aware of diagnosis
- 1H4..00 Child aware of parent diagnosis
- 66W3.00 Aware of prognosis
- 66W3000 Carer aware of prognosis
- 66W3100 Relative aware of prognosis
- 66W4.00 Unaware of prognosis
- 66W4000 Carer unaware of prognosis
- 67D1.00 Informing patient of prognosis
- 67F1.00 Informing relative of prognosis
- Cancer Treatment Arrangements – Displays and allows you to record the following:
- 59...00 External Radiotherapy
- 59...11 X-ray therapy - external
- 7M37100 Radiotherapy NEC
- 8BAD000 Cancer Chemotherapy
- 8BC6.00 Cancer treatment started
- 8BC3 Cancer care plan given
- 8BCF.00 Cancer hospital treatment completed
- 8BJ..00 Treatment intent
- 8BJ0.00 Curative treatment
- 8BJ1.00 Palliative Treatment
- 8BJ2.00 Supportive care
- 8CRC Cancer chemotherapy management plan
- 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* - This information is shared with KIS - See Adding Data to the Key Information Summary
- Other Agencies involved*– This information is shared with KIS - See Adding Data to the Key Information Summary
- 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.
Correct DNACPR Form 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
- 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 displays.
- Moving and Handling Equipment at Home – 13CX.00 Moving and handling equipment available at home
- Has Advance Care Plan - 8CME Has end of life advance care plan
- Preferred Place of Care – This information is shared with the KIS screen. See Adding Data to the Key Information Summary.
- Preferred Place of Final Care – This information is shared with the KIS screen. See Adding Data to the Key Information Summary.
- 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 KIS 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.
