Personalised Care & Support Plan

This is not a legally binding document but a supportive tool which may be amended at any time. This plan should be completed with the patient/relevant others by a professional with the required training & skillset
	
PATIENT DETAILS	

Name: Title Given Name Surname
	Date of Birth: Date of Birth	
NHS Number: NHS Number	Gender: Gender(full)	
Ethnicity: Ethnic Origin	Main Language: Main Language	
Home Address: Home Full Address (single line) 
	
Home Telephone No.: Patient Home Telephone 	Mobile Telephone No.: Patient Mobile Telephone 	
GP DETAILS	
GP Name: Usual GP Title Usual GP Forenames Usual GP Surname	
GP Surgery: Usual GP Organisation Name	GP Telephone: Usual GP Phone Number	
GP Address: Usual GP Full Address (single line) 
	
KEY CONTACT (Ideally Next Of Kin/ Lasting Power of Attorney)	
Name: Free Text Prompt 	Role: Free Text Prompt	
Telephone Number: Free Text Prompt 		
LIVING ARRANGMENTS	
Home
 Alone    With Someone   	Care Home  
Residential     Nursing    	No fixed abode 
  	
What support does the patient have living at home? e.g. care package
	
SIGNIFICANT DOCUMENTS	
Lasting Power of attorney health & wellbeing	Yes     No   Name:	
Lasting Power of attorney finance	Yes     No   Name:	
Advance decision to refuse treatment	Yes     No  	
Advance statement of wishes & preferences	Yes     No  	
GOLD STANDARDS FRAMEWORK	Single Code Entry: On gold standards palliative care framework  	
CPR Status – Complete if applicable 	Single Code Entry: Not for attempted cardiopulmonary resuscitation 
 	
ANTICIPATORY CLINICAL MANAGEMENT PLAN (ACMP)	
CLINICAL GUIDANCE FOR URGENT/ EMERGENCY CARE AND TREATMENT	
The key aim of future clinical care - shared with the patient and/or Next Of Kin/ Carer	

For all active treatment    
	Palliative approach   
	Care of the dying    

What clinical events can you anticipate?

Specific guidance to manage this event
		
RECOMMENDATION FOR TREATMENT ESCALATION & TRANSFER TO A HOSPITAL 	
Hospitalisation if deemed helpful or essential 	  	
Management within the home setting to be the primary aim where possible	  	
Express wish not to be transferred/admitted to hospital even if life at risk	  	
Comment if helpful:
 	
PATIENT’S PERSEPECTIVE    (Or Next Of Kin/ Carer if patient is unable to engage)	
What does the patient understand about their current illness?

“What matters to me” e.g. who might the patient want with them, their spiritual needs etc

PREFERRED PLACE OF CARE 
(In case of serious or progressive illness)	Single Code Entry: Preferred place of care - home...  	
BASELINE FUNCTION	
OXYGEN SATURATION (if relevant)	Single Code Entry: Blood oxygen saturation (calculated)...  	
MOBILITY (X)	Fully mobile                Wheelchair   
Walking aids                  Bedbound    	
WHO PERFORMANCE SCORE	Single Code Entry: WHO performance score..	
COMMON GERIATRIC ASSESSMENT DOMAINS  (Applicable in frail and care home patients)	
Physical	Mobility/balance	Functional	
Psychological/mental	Medication review	Socioeconomic/environmental	

Please identify if there are any specific issues or unmet needs against the domains as applicable

Unmet need:

Proposal:
	
No immediate unaddressed needs with regards to the domains of the CGA		
INFORMATION TO ASSIST PATIENTS WITH PARTICULAR NEEDS  
e.g. Visual, hearing, Activities of Daily Living,	

CURRENT MEDICAL PROBLEMS – Only include those problems relevant to this plan	
Active 
Problems 
Significant Past
Problems  
	
Allergies & Adverse Drug Reactions	
Allergies 
	
SHARING THIS CARE PLAN & NOTIFICATIONS (X)	
Patient’s home (hard copy)		
Ambulance Service NWAS via ERISS	Code from EMIS	
Out of Hours Provider (special note)	Code from EMIS	
Other		
CARE PLAN AGREEMENT	
Healthcare Professional who has completed the care plan 	
Name:	Free Text Prompt 	Role:	Free Text Prompt 	
Date:	Long date letter merged 	

Was the patient involved in the development of this plan? 	
Yes          No  	
If “No” how was the plan developed?	
Confirmation that the patient/ nominated deputy agrees with the care plan, its contents and for it to be shared with professionals who may be involved in their future care. 
For patients who lack capacity   
Name of the person above: 
Relationship to the Patient:	Yes          No  	
Consent to share 	Single Code Entry: Consent given for sharing end of life care coordination record
Single Code Entry: Withdrawal of consent for sharing end of life care coordination record  
Single Code Entry: Best interest decision taken for sharing end of life care coordination record  
Single Code Entry: Consent given by appointed person with lasting power of attorney for personal welfare (Mental Capacity Act 2005) for sharing end of life care coordination record