Publication - Factsheet

Anticipatory Care Planning: Frequently Asked Questions

Published: 20 Apr 2010
Part of:
Health and social care
ISBN:
9780755992133

To provide practical support and guidance on long term condition anticipatory care plans.

21 page PDF

0 B

21 page PDF

0 B

Contents
Anticipatory Care Planning: Frequently Asked Questions
Appendix 1: The electronic Palliative Care Summary

21 page PDF

0 B

Appendix 1: The electronic Palliative Care Summary

The electronic Palliative Care Summary ( ePCS) - Update November 2009

ePCS is a significant development which allows GPs and District Nurses to record information on the palliative and end of life needs of their patients onto their GP software system, and for this to be available to those providing care in the Out of Hours period

What is ePCS?

The ePCS builds on the Emergency Care Summary ( ECS) and the Gold Standards Framework Scotland ( GSFS) projects. The ePCS will, with patient/carer consent, allow automatic twice-daily updates of information from GP records to a central store, from where they will be available to Out of Hours ( OOH document, plan and review care. A paper Palliative Care Summary can be printed off and sent to OOH. Ultimately, ePCS will replace information currently faxed/emailed to OOH providers for palliative patients. Once your practice is "switched on" for ePCS, and patient consent is obtained and recorded on the GP system, all information will be available) services, NHS 24, Acute Receiving Units, Accident and Emergency Departments and, shortly, to the Scottish Ambulance Service. This will allow vital, structured information to support these patients and their families to be available in hours and OOH.

Pilot phase complete - now starting rollout

Following positive pilots in NHS Grampian, Lothian and Ayrshire & Arran, the ePCS is being rolled out Board-wide in Lothian starting September 2009 and will be rolled out nationally from late 2009 on a Board by Board basis.

Using ePCS in the practice

Practices will notice new software on their GP system which allows information on patients with palliative care needs to be recorded in one place, prompts to record patient's wishes, prompts for Anticipatory Care and review dates. The system also produces patient lists for team meetings and helps fulfil the Palliative Care DES. Prior to Board-wide roll out, practices can use the ePCS locally i.e. without transmitting to ECS, as it gives prompts and helps to end users in OOH, NHS24 and A+E Departments.

Patient consents to share How does ePCS work? electronic Palliative Care Summary ( ePCS) Patient/Carer calls NHS24

Patient consents to share How does ePCS work? electronic Palliative Care Summary (ePCS) Patient/Carer calls NHS24

How will ePCS be seen in OOH?

Out of Hours access will be via NHS24 and for most boards will be via the Adastra OOH system. Adastra has also been adapted to include access to ePCS in cars to enable access for staff in remote areas or on call. For Out of Hours access in boards where Taycare is used, developments are underway and a timescale will be confirmed by NHS Tayside as soon as possible.

What information is recorded and sent in ePCS?

Information will be recorded in the GP system to form an Anticipatory Care Plan which will be available OOH and includes:

  • Prescribed Medication (all Repeat & last 30 days Acute) & Allergies as per ECS
  • Medical Diagnoses - as agreed between GP and patient
  • Patients and Carers' understanding of diagnosis and prognosis
  • Patient wishes - e.g. Preferred Place of Care & resuscitation ( DNACPR)
  • Information on medication/equipment left in patients' home, "Just In Case"

ePCS - Full Information sent from GP systems

Date - Updated when sent to ECS

Date - Patient review Date

Patient & Carer Details

Patient's Own GP and Nurse

Review date

Usual GP name

Patient Surname

Nurse

Patient Forenames

Practice details

CHI Number

Patient Address & Tel Number

Carer Details

Access Information / potential issues

Next of kin details

Patient Medical Condition

Current Care Arrangements

Main diagnoses

Care arrangements

Other relevant issues

Syringe driver at home

Allergies/Drug reactions

Catheter continence products at home

Current drugs and doses

Moving and Handling equipment at home

Additional drugs available at home

Patient's and Carer's Awareness of Condition

Advice for Out Of Hours Care

Patient's understanding of Diagnosis

Care Plan agreed

Patient's understanding of Prognosis

Preferred place of care

Carer's understanding of Diagnosis

Should GP be contacted out of hours?

Carer's understanding of Prognosis

GP Home telephone/mobile/pager

Resuscitation status agreed?

Actual resuscitation status

For more information, including ePCS Patient Information Leaflets, and training materials see
http://www.ecs.scot.nhs.uk/epcs.html and for more information on the national programme Living and Dying Well; see www.scotland.gov.uk/livinganddyingwell

Dr Peter Kiehlmann, GP, Aberdeen and National Clinical Lead Palliative Care eHealth SGHD
Email peter.kiehlmann@scotland.gsi.gov.uk

Marysia WilliamsonePCS Project Manager, NSS, Edinburgh
Email: Marysia.williamson@nhs.net