ID:3974174310          
<?xml version="1.0" encoding="UTF-8" ?><SystmOneTemplates><!--Exported on 03 Jan 2020 11:10--><!--Exported by PLENDERLEITH, Steve (Dr)--><TemplateDefinition Male="y" Female="y" Type="0"><template Cid="0" width="972" height="636" codes="" readCodesToAutoLinkDrugsTo="" codesToAlwaysInclude="" keyWordLetterTemplateDefaultForPrinting="-1"><page Cid="211" name="Introduction &amp; Patient Consent" colour="-1"><hyperLink Cid="212" x="780" y="12" w="180" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><formattedText Cid="229" x="237" y="12" w="555" h="36"><p><p><t sz="16" b="b" fg="0xff005eb8">For project information, template updates and additional resources.</t></p></p></formattedText><formattedText Cid="320" x="12" y="12" w="204" h="60"><p><p><t sz="20" b="b">Introduction &amp;</t></p><p><t sz="20" b="b">Patient Consent</t></p></p></formattedText><formattedText Cid="224" x="324" y="36" w="472" h="41"><p><p><t fnt="Arial" sz="14" b="b" fg="0xff005eb8">Project supported as part of an NHS and Hospice partnership:</t></p></p></formattedText><hyperLink Cid="309" x="780" y="36" w="180" h="24" URL="http://www.futureplanning.org.uk/supported_by.html" DisplayText="Supported by"/><formattedText Cid="377" x="12" y="84" w="936" h="72"><p><p><t>The main purpose of this template set is to provide </t><t sz="14" b="b" fg="0xffff0000">a summary</t><t> of the patient&apos;s clinical information to the Summary Care Record (SCR)</t></p><p><t>.</t></p><p al="1"><t sz="14" b="b" fg="0xffff0033">Please keep freetext succinct, understandable and relevant to the question asked / box title</t></p></p></formattedText><formattedText Cid="272" x="12" y="144" w="936" h="60"><p><p><t>By accessing the Summary Care Record during Emergency / Acute Care episodes;</t></p><p><t>&#x9;&#x9;&#x9;- Ambulance Triage (999/111) and paramedic crews, GP OOH services, MAU, ED and any other hospital staff, </t></p><p al="2"><t>with an NHS smartcard, will be able to access this summary information to guide their clinical responses. </t></p></p></formattedText><formattedText Cid="382" x="228" y="216" w="504" h="36"><p><p><t sz="14" b="b" fg="0xffcc00cc">THIS IS THE MOST IMPORTANT CODE IN THE WHOLE TEMPLATE</t><t sz="10" fg="0xffcc00cc">, bar none.</t></p></p></formattedText><hline Cid="380" x="156" y="204" length="648"/><checkBox Cid="317" x="168" y="252" w="624" text="Enhanced consent to share - allows Additional Information upload to the Summary Care Record" journal="y" summary="y" amendNotes="y" blank="n" showTimeComponent="n" code="XaXbZ" reportDefault="-1"/><notes Cid="318" x="480" y="432" w="468" h="168" text="Person giving consent and rationale if NOT patient" journal="y" summary="y" bias="60" amendNotes="n" blank="n" showTimeComponent="n" code="XaaYM" orientation="Top" presetNotes=""/><formattedText Cid="316" x="12" y="300" w="936" h="132"><p><p al="1"><t fg="0xff660066">The &quot;</t><t sz="14" b="b" fg="0xffff0033">Enhanced </t><t sz="14" b="b" fg="0xffff0000">Consent</t><t fg="0xff660066">&quot; tick box above will enable </t><t u="u" sz="14" b="b" fg="0xff660066">information from this set of templates</t><t b="b" fg="0xff660066"> to show in the patient&apos;s national Summary Care Record</t><t fg="0xff660066">. </t></p><p al="1"><t fg="0xff660066">In addition, some other coded information from the GP record, including diagnoses and involved teams, will also be shared to the SCR.</t></p><p/><p><t sz="14" b="b" fg="0xff660066">Verbal or written consent is acceptable. Consent may also be gained by other clinical teams who should pass this info to the practice as, currently, only GP practices can record this code in the patient record.</t></p><p><t fg="0xff660066">If a patient has a persistent lack of capacity for giving this consent, then their legal representative (LPoA for H&amp;W, court appointed guardian) or an appropriate clinician (ideally with MDT backing) should, acting in the patients best interests, add this consent code to the patient record.</t></p></p></formattedText><comboBox Cid="405" x="12" y="516" w="444" text="Register &amp; / OR prognosis" bias="65" amendNotes="y" blank="n" showTimeComponent="n" codes="XaKdU;XaZ7j;X76Ao;Xa982;XaZb7;XaZbA;XaZbD;XaZbE"><rc rc="XaKdU" desc=""/><rc rc="XaZ7j" desc=""/><rc rc="X76Ao" desc=""/><rc rc="Xa982" desc=""/><rc rc="XaZb7" desc=""/><rc rc="XaZbA" desc=""/><rc rc="XaZbD" desc=""/><rc rc="XaZbE" desc=""/></comboBox><formattedText Cid="406" x="96" y="552" w="204" h="24"><p><p><t b="b">May be used in some practices.</t></p></p></formattedText><formattedText Cid="407" x="12" y="480" w="444" h="29"><p><p><t sz="16" b="b" fg="0xff05db05">Add patient to a Practice Register ?</t></p></p></formattedText><vline Cid="379" x="816" y="204" length="84" vertical="y"/><hline Cid="381" x="156" y="288" length="648"/><vline Cid="378" x="144" y="204" length="84" vertical="y"/><formattedText Cid="331" x="12" y="612" w="936" h="26"><p><p al="1"><t sz="14" b="b" fg="0xffef3511">V 3.1</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">Future Planning Template</t><t sz="14" fg="0xffef3511"> - November 2019             </t><t sz="14" fg="0xff330033"> &#169; Copyright reserved. Southern Health NHS Foundation trust </t></p></p></formattedText></page><page Cid="49" name="Treatment Escalation" colour="-3358246"><title Cid="50" x="24" y="12" width="348" text="Treatment Escalation Planning TEP"/><hyperLink Cid="156" x="780" y="12" w="180" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><notes Cid="54" x="24" y="60" w="924" h="72" text=" Emergency contact details." summary="y" bias="70" amendNotes="n" blank="n" showTimeComponent="n" code="XaXTm" presetNotes="Contacts information entered elsewhere in SystmONE is unlikely to be visible to acute care teams via the Summary Care Record.;1st Contact Name:    Tel./Mobile:      Alt. Tel:       Address:         Awareness of wishes/other notes:;2nd Contact Name:   Tel./Mobile:      Alt. Tel:       Address:         Awareness of wishes/other notes:"/><notes Cid="53" x="492" y="144" w="456" h="96" text="Home access info &amp; risks eg pets &amp; other" journal="y" level="3" problem="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaYR5" orientation="Top" presetNotes=""/><multiple Cid="122" x="24" y="156" w="444" h="84" text="Power of Attorney" summary="y" bias="75" amendNotes="y" blank="n" showTimeComponent="n" codes="XaYlh;XaOc5;Ua0Sq;XaOc4;Ua0Sn"><rc rc="XaYlh" desc=""/><rc rc="XaOc5" desc=""/><rc rc="Ua0Sq" desc=""/><rc rc="XaOc4" desc=""/><rc rc="Ua0Sn" desc=""/></multiple><formattedText Cid="270" x="84" y="576" w="204" h="60"><p><p><t sz="11" fg="0xff660066">Where is the original stored?</t></p><p><t sz="11" fg="0xff660066">Add a summary of relevant details:</t></p></p></formattedText><notes Cid="59" x="24" y="552" w="924" h="72" text="Has Advance Decision to Refuse Treatment (ADRT)" summary="y" bias="70" amendNotes="n" blank="n" showTimeComponent="n" code="XaYld" presetNotes="Where is the ADRT held:-;|Briefly record issues covered by the ADRT:-;|In which settings do these apply:-"/><formattedText Cid="172" x="24" y="252" w="936" h="132"><p><p><t fnt="Arial" sz="14" b="b">Treatment Escalation Planning (TEP) Levels</t></p><p><t fnt="Arial" sz="14" b="b" fg="0xff660066">Intensive:</t><t fnt="Arial" fg="0xff660066">&#x9;Transfer to hospital for treatment if appropriate. Critical care, intubation and ventilation should be considered.</t></p><p><t fnt="Arial" sz="14" b="b" fg="0xff660066">Hospital:</t><t fnt="Arial" fg="0xff660066">&#x9;Transfer to hospital if appropriate, but not for critical care, intubation or ventilation.</t></p><p><t fnt="Arial" sz="14" b="b" fg="0xff660066">Home: </t><t fnt="Arial" fg="0xff660066">&#x9;Treat with normal and rescue medications (mostly oral, nebs, SC &amp;/or syringe driver) at home with support from GP. Admission to hospital to be avoided unless measures fail and following discussion with Palliative Care or other involved Specialist Team and GP.</t></p><p><t fnt="Arial" sz="14" b="b" fg="0xff660066">Comfort:</t><t fnt="Arial" fg="0xff660066">&#x9;Palliative Meds via SC, oral or per rectal route, positioning, wound care and other measures to relieve symptoms. Admission to hospital to be avoided unless comfort measures fail and following discussion with Palliative Care Team.</t></p></p></formattedText><comboBox Cid="52" x="359" y="29" w="396" text="Who does the patient live with?" summary="y" amendNotes="y" blank="n" showTimeComponent="n" codes="13F2.;13F3.;13FH.;Ua0Ig;Ua0IT;Ua0Lj;XaAyp"><rc rc="13F2." desc=""/><rc rc="13F3." desc=""/><rc rc="13FH." desc=""/><rc rc="Ua0Ig" desc=""/><rc rc="Ua0IT" desc=""/><rc rc="Ua0Lj" desc=""/><rc rc="XaAyp" desc=""/></comboBox><notes Cid="181" x="24" y="372" w="924" h="168" text="Anticipated problems due to medical conditions" summary="y" bias="70" amendNotes="n" blank="n" showTimeComponent="n" code="XacZx" orientation="Top" presetNotes="Example: Lower Respiratory Tract Infection      Rx Level: HOME      Management &amp; Patient Wishes: For trial of PO antibiotics, not for IV, if deteriorates stop antibiotics and palliate;Problem: Signs of infection e.g. UTI                      TEP Level:                   Mx &amp; Wishes:;Problem: Poor oral intake/f ood &amp; fluid                  TEP Level:                  Mx &amp; Wishes:;Problem: Falls without obvious injury                    TEP Level:                  Mx &amp; Wishes:;Problem: Falls with suspected injury or fracture  TEP Level:                  Mx &amp; Wishes:;Problem: Signs of possible CVA                             TEP Level:                  Mx &amp; Wishes:;Problem:                                                                      TEP Level:                  Mx &amp; Wishes:"/><textarea Cid="400" x="60" y="180" w="72" h="53" text="Select all that are relevant."/></page><page Cid="107" name="TEP Observations" colour="-3096098"><title Cid="134" x="24" y="12" width="348" text="Observations to be considered "/><hyperLink Cid="157" x="780" y="12" w="180" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><notes Cid="135" x="12" y="48" w="936" h="48" text="If diabetic, usual BM range &amp; response if abnormal" summary="y" bias="70" amendNotes="n" blank="n" showTimeComponent="n" code="XaJYg" presetNotes=""/><checkBox Cid="137" x="552" y="108" w="396" text="Known Chronic type 2 respiratory failure" amendNotes="y" blank="n" showTimeComponent="n" code="XaO5m" reportDefault="-1"/><title Cid="125" x="12" y="108" width="514" text="CO2 Retention Risk Factors (BTS guidelines 2012)"/><formattedText Cid="395" x="240" y="612" w="612" h="24"><p><p><t>Please tick this box if information has passed to the practice using the Future Planning: My Wishes form.</t></p></p></formattedText><checkBox Cid="394" x="240" y="588" w="432" text="FP: My Wishes leaflet patient info added" date="y" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaZYs" reportDefault="-1"/><hline Cid="393" x="696" y="588" length="251"/><hline Cid="422" x="24" y="588" length="204"/><textarea Cid="124" x="12" y="132" w="432" h="192" text="|Patients may be at risk of CO2 retention and therefore respiratory depression with higher oxygen concentrations if:|&#8226;    They have a past history of CO2 retention|&#8226;    They have chronic chest disease, such as COPD, musculoskeletal disease or chronic neuromuscular conditions|&#8226;    They have all 3 of the following risk factors; |    &#x9;           o    long term smoker|&#x9;           o    &gt;50 years old|&#x9;           o    unexplained exertional dyspnoea|"/><notes Cid="136" x="480" y="144" w="468" h="204" text="Patient at risk of CO2 retention - please document" journal="y" bias="70" level="3" problem="y" amendNotes="n" blank="n" showTimeComponent="n" code="P8yz." orientation="Top" presetNotes=""/><notes Cid="138" x="12" y="360" w="936" h="60" text="Home O2- reason for use &amp; acceptable O2 sats range" summary="y" bias="70" amendNotes="n" blank="n" showTimeComponent="n" code="XE1Sx" presetNotes=""/><formattedText Cid="423" x="36" y="384" w="192" h="42"><p><p><t>Face mask, nasal specs,</t></p><p><t>any special equipment needs.</t></p></p></formattedText><notes Cid="404" x="12" y="432" w="936" h="60" text="Cardiovascular issues - record useful information" summary="y" bias="70" level="3" amendNotes="n" blank="n" showTimeComponent="n" code="XaaBH" presetNotes=""/><formattedText Cid="403" x="36" y="456" w="261" h="42"><p><p><t>Patient&apos;s usual heart rate &amp; rhythm or any other abnormalities.</t></p></p></formattedText><notes Cid="139" x="12" y="504" w="936" h="60" text="Any longstanding abnormal signs or findings" journal="y" summary="y" bias="70" level="2" amendNotes="n" blank="n" showTimeComponent="n" code="2Z..." presetNotes=""/></page><page Cid="280" name="CPR Decision" colour="-1712148"><hyperLink Cid="283" x="768" y="12" w="180" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><formattedText Cid="282" x="24" y="12" w="616" h="36"><p><p><t fnt="Arial" sz="18" b="b" fg="0xffff0033">CARDIOPULMONARY RESUSCITATION DECISIONS</t></p></p></formattedText><comboBox Cid="408" x="24" y="156" w="432" text="Patient CPR status" bias="65" amendNotes="y" blank="n" showTimeComponent="n" codes="XaZVX;XaZ9c"><rc rc="XaZVX" desc=""/><rc rc="XaZ9c" desc=""/></comboBox><formattedText Cid="409" x="24" y="180" w="432" h="24"><p><p><t b="b" fg="0xffff0000">This record does NOT replace the need for a uDNACPR or ReSPECT form</t></p></p></formattedText><multiple Cid="410" x="504" y="144" w="432" h="96" text="Awareness of CPR" summary="y" bias="65" amendNotes="y" blank="n" showTimeComponent="n" codes="XacXn;XacqN;XacqM;XaZZn"><rc rc="XacXn" desc=""/><rc rc="XacqN" desc=""/><rc rc="XacqM" desc=""/><rc rc="XaZZn" desc=""/></multiple><formattedText Cid="411" x="492" y="168" w="156" h="36"><p><p al="2"><t sz="11">Discussions or Decisions</t></p></p></formattedText><textarea Cid="412" x="552" y="204" w="86" h="43" text="Select all that are relevant."/><formattedText Cid="416" x="12" y="612" w="456" h="26"><p><p al="1"><t sz="14" b="b" fg="0xffef3511">VERSION 3.1</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">Future Planning Template</t><t sz="14" fg="0xffef3511"> - November 2019</t></p></p></formattedText><formattedText Cid="391" x="24" y="60" w="408" h="72"><p><p><t fnt="Comic Sans MS" sz="18" fg="0xff660066">THIS PAGE WILL BE DEVELOPED FURTHER...</t></p><p/><p><t fnt="Arial" sz="14">In the meantime........</t></p></p></formattedText></page><page Cid="33" name="My Wishes" colour="-3342388"><hyperLink Cid="155" x="780" y="12" w="180" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><title Cid="413" x="24" y="12" width="351" text="Future Planning: My Wishes"/><formattedText Cid="417" x="24" y="612" w="456" h="26"><p><p al="1"><t sz="14" b="b" fg="0xffef3511">VERSION 3.1</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">Future Planning Template</t><t sz="14" fg="0xffef3511"> - November 2019</t></p></p></formattedText><hline Cid="45" x="36" y="504" length="902"/><multiple Cid="99" x="336" y="516" w="600" h="72" text="Other involved specialist teams" summary="y" bias="65" amendNotes="y" blank="n" showTimeComponent="n" codes="XaIN4;XaAP9;XaJO4;XaIN5;XaAPj;YA483;XaIvk;XaAPU;XaAOr;XaARD;XaAPC;XaARU;XaAQQ;XaE4n"><rc rc="XaIN4" desc=""/><rc rc="XaAP9" desc=""/><rc rc="XaJO4" desc=""/><rc rc="XaIN5" desc=""/><rc rc="XaAPj" desc=""/><rc rc="YA483" desc=""/><rc rc="XaIvk" desc=""/><rc rc="XaAPU" desc=""/><rc rc="XaAOr" desc=""/><rc rc="XaARD" desc=""/><rc rc="XaAPC" desc=""/><rc rc="XaARU" desc=""/><rc rc="XaAQQ" desc=""/><rc rc="XaE4n" desc=""/></multiple><textarea Cid="402" x="480" y="540" w="72" h="53" text="Select all that are relevant."/><title Cid="46" x="84" y="516" width="204" text="Support Available"/><hyperLink Cid="425" x="804" y="72" w="141" h="24" URL="https://www.ageuk.org.uk/information-advice/health-wellbeing/relationships-family/end-of-life-issues/talking-death-dying/" DisplayText="AgeUK Booklet"/><hyperLink Cid="426" x="804" y="108" w="139" h="24" URL="https://www.youtube.com/watch?v=4Bfomd2mq7w" DisplayText="AgeUK Video"/><notes Cid="97" x="492" y="420" w="456" h="72" text="Wishes to be tissue donor. Please give details " journal="y" level="2" problem="y" amendNotes="n" blank="n" showTimeComponent="n" code="139.." orientation="Top" presetNotes="Please provide details;|Any wish or objections to donating specific organs or tissues;|Issues discussed with patient and/or  family;|Patient/family/NoK understanding of the process of donation after death;|Any arrangements agreed with University, Research or other organisations. Please give contact details."/><notes Cid="132" x="24" y="420" w="432" h="72" text="Referral to coroner required. Please give details." summary="y" bias="35" amendNotes="n" blank="n" showTimeComponent="n" code="Xab5P" orientation="Top" presetNotes="Reason for referral?;|Is patient / family aware of need for referral?;|Has discussion taken place with coroner already?;|"/><notes Cid="250" x="24" y="324" w="924" h="84" text="Wishes &amp; requirements following death. " summary="y" bias="70" amendNotes="n" blank="n" showTimeComponent="n" code="94Z.." presetNotes="Are there any religious,cultural, family or patient requirements/wishes?|E.g. Preparation of the body.|Is the patient to be buried or cremated?|A patient with a fear of being &quot;buried alive&quot; may be re-assured to see this raised to ensure that Verification is undertaken thoroughly.|If an undertaker has already been identified, please detail here.;||Concerns regarding bereavement?"/><title Cid="40" x="84" y="288" width="357" text="Considerations for care after death"/><hline Cid="39" x="12" y="276" length="948"/><comboBox Cid="94" x="24" y="240" w="432" text="Preferred place of death" journal="y" summary="y" bias="65" level="2" amendNotes="y" blank="n" showTimeComponent="n" codes="XaJ3g;XaJ3h;XaJ3k;XaJ3j;XaJ3i;XaQiX;XaYsj;XaQzq;XaQzt;XaQzr;XaXOt"><rc rc="XaJ3g" desc=""/><rc rc="XaJ3h" desc=""/><rc rc="XaJ3k" desc=""/><rc rc="XaJ3j" desc=""/><rc rc="XaJ3i" desc=""/><rc rc="XaQiX" desc=""/><rc rc="XaYsj" desc=""/><rc rc="XaQzq" desc=""/><rc rc="XaQzt" desc=""/><rc rc="XaQzr" desc=""/><rc rc="XaXOt" desc=""/></comboBox><comboBox Cid="38" x="504" y="240" w="444" text="Status of internal cardiac defibrillator" amendNotes="y" blank="n" showTimeComponent="n" codes="Xa8D5;XaNR7;XaYZM"><rc rc="Xa8D5" desc=""/><rc rc="XaNR7" desc=""/><rc rc="XaYZM" desc=""/></comboBox><notes Cid="93" x="24" y="156" w="924" h="72" text="Patient, Family/NoK wishes &amp; preferences for care" summary="y" bias="70" amendNotes="n" blank="n" showTimeComponent="n" code="XaXUG" presetNotes="This section provides space to record the hopes, wishes and preferences of those involved in the remaining life of this patient. And their concerns and fears.;|Preferences that are not specific enough for an ADRT form could be recorded here.;|A description of family dynamics!;|Difficulties with communication?;|In short anything that may help to inform clinical and social care staff to provide more effective care and support.;||Management of anticipated medical problems should be entered on the Avoiding Unplanned Admissions 1 TAB."/><title Cid="34" x="84" y="120" width="351" text="Considerations for ongoing care "/><formattedText Cid="424" x="24" y="48" w="768" h="96"><p><p al="1"><t fg="0xff990099">Please use the </t><t b="b" fg="0xff990099">Future Planning: My Wishes leaflet</t><t fg="0xff990099"> to help patients/families take forward conversations between your visits.</t></p><p al="1"/><p al="2"><t fg="0xff990099">Directing appropriate patients and families towards the Age UK </t><t b="b" fg="0xff990099"> Let&apos;s talk about death and dying booklet</t></p><p al="2"><t fg="0xff990099">and </t><t b="b" fg="0xff990099">video</t></p><p al="2"><t fg="0xff990099">may also be helpful.</t></p></p></formattedText></page><page Cid="182" name="Frailty" colour="-3342337"><hyperLink Cid="189" x="780" y="12" w="180" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><title Cid="187" x="24" y="24" width="276" text="Frailty Assessment"/><formattedText Cid="418" x="24" y="612" w="456" h="26"><p><p al="1"><t sz="14" b="b" fg="0xffef3511">VERSION 3.1</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">Future Planning Template</t><t sz="14" fg="0xffef3511"> - November 2019</t></p></p></formattedText><notes Cid="200" x="84" y="468" w="780" h="120" text="Frailty Review - meeting notes and date" date="y" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="X76Ao" orientation="Top" presetNotes=""/><hline Cid="223" x="24" y="444" length="924"/><notes Cid="190" x="24" y="132" w="444" text="eFI Frailty Index Score" date="y" summary="y" bias="30" amendNotes="n" blank="n" showTimeComponent="n" code="XabYS" presetNotes=""/><formattedText Cid="185" x="24" y="84" w="444" h="48"><p><p><t>To calculate the eFI scores for patients in your practice please see the SystmONE electronic Frailty Report in &quot;Reporting &gt; Miscellaneous Reports&quot;.</t></p></p></formattedText><hyperLink Cid="311" x="24" y="204" w="443" h="24" URL="www.futureplanning.org.uk/rockwood" DisplayText="Also known as the ROCKWOOD SCALE - click to view"/><number Cid="201" x="24" y="180" w="444" text="Canadian Study of Health and Aging clinical frailty scale" bias="25" amendNotes="n" blank="n" showTimeComponent="n" code="XaQik" pvlimit="Last" pvtime="12" pvunit="Wks"/><multiple Cid="428" x="24" y="324" w="444" h="48" text="Risk Factors for Falls" summary="y" bias="70" amendNotes="y" blank="n" showTimeComponent="n" codes="Xa1GP;Xa6tR;Xa23O;XaELC;XE16L;Ua189;XaKdS;8B36.;XaJLQ"><rc rc="Xa1GP" desc=""/><rc rc="Xa6tR" desc=""/><rc rc="Xa23O" desc=""/><rc rc="XaELC" desc=""/><rc rc="XE16L" desc=""/><rc rc="Ua189" desc=""/><rc rc="XaKdS" desc=""/><rc rc="8B36." desc=""/><rc rc="XaJLQ" desc=""/></multiple><formattedText Cid="427" x="24" y="300" w="444" h="24"><p><p><t>NICE 2013 - Multifactorial Falls Risk Assessment</t></p></p></formattedText><formattedText Cid="275" x="336" y="252" w="150" h="24"><p><p><t sz="11">Enter &quot;0&quot; if no falls.</t></p></p></formattedText><number Cid="221" x="24" y="252" w="443" text="Number of falls in the last 12 months" journal="y" summary="y" level="2" amendNotes="n" blank="n" showTimeComponent="n" code="XaISO" pvlimit="Last" pvtime="1" pvunit="Yrs"/><notes Cid="195" x="324" y="36" w="444" h="28" text="Named accountable GP" summary="y" bias="70" amendNotes="n" blank="n" showTimeComponent="n" code="XacWQ" presetNotes=""/><comboBox Cid="220" x="228" y="408" w="504" text="Frailty Assessment Conclusion" journal="y" bias="60" level="2" amendNotes="n" blank="n" showTimeComponent="n" codes="XabdY;Xabdb;Xabdd"><dependency cid="201" comparison="7" value="0.0" keyReport="-1"/><dependency cid="221" comparison="9" value="0.0" keyReport="-1"/><dependencyMode mode="0"/><rc rc="XabdY" desc=""/><rc rc="Xabdb" desc=""/><rc rc="Xabdd" desc=""/></comboBox><formattedText Cid="429" x="24" y="372" w="250" h="24"><p><p><t sz="11" fg="0xffcc0033">Most items in this list do not upload to the SCR</t></p></p></formattedText><notes Cid="222" x="504" y="276" w="443" h="120" text="Falls assessment" date="y" journal="y" summary="y" eipsodicity="2" level="2" problem="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaJL7" orientation="Top" presetNotes="Consider items flagged by the Multifactorial Falls Risk Assessment. Briefly document issues &amp; how these are being addressed.;      Medication or other iatrogenic causes of fatigue, weakness, altered balance or reduced concentration..;      Deficiencies of nutrition, fluid, vitamins, minerals or stimulation, including exercise.;       Opportunities for socialisation, rehabilitation &amp;/or modifications to the environment."/><formattedText Cid="430" x="504" y="228" w="250" h="24"><p><p><t sz="11" fg="0xffcc0033">This item does not upload to the SCR</t></p></p></formattedText><notes Cid="219" x="504" y="108" w="443" h="120" text="Polypharmacy medication review" date="y" journal="y" eipsodicity="2" level="2" amendNotes="n" blank="n" showTimeComponent="n" code="XaaCQ" orientation="Top" presetNotes="       Anticholinergic Medications &amp; reasons for continued use;       Reduced eGFR and current medications affected by this;       Minimising sedating drugs.;       Reduction or alteration of dosing with altered BMI.;Consider the 7 Steps;Step 1: What matters to the patient;Step 2: Identify essential drug therapy;Step 3: Does the patient take unnecessary drug therapy?;Step 4: Are therapeutic objectives realistic and being achieved?;Step 5: Is the patient at risk of or do they suffer from actual Adverse Drug Reactions (ADRs)?;Step 6: Is drug therapy cost effective?;Step 7: Is the patient willing and able to take drug therapy as intended?"/><formattedText Cid="431" x="540" y="84" w="132" h="36"><p><p><t sz="14" b="b">NHS Scotland</t></p></p></formattedText><hyperLink Cid="432" x="672" y="84" w="192" h="24" URL="http://www.polypharmacy.scot.nhs.uk/polypharmacy-guidance-medicines-review/for-healthcare-professionals/7-steps/" DisplayText="Medication Review"/></page><page Cid="10" name="Prognosis &amp; GSF Meeting" colour="-3342388"><title Cid="11" x="24" y="12" width="396" text="Prognosis &amp; GSF Meeting"/><hline Cid="258" x="12" y="120" length="936"/><textarea Cid="262" x="552" y="48" w="72" h="53" text="Select all that are relevant."/><multiple Cid="202" x="480" y="12" w="468" h="108" text="Awareness of Prognosis" summary="y" bias="65" amendNotes="y" blank="n" showTimeComponent="n" codes="XaQIy;XaVzA;XaX1d;XaVzE;XaX1e;XaXBG"><rc rc="XaQIy" desc=""/><rc rc="XaVzA" desc=""/><rc rc="XaX1d" desc=""/><rc rc="XaVzE" desc=""/><rc rc="XaX1e" desc=""/><rc rc="XaXBG" desc=""/></multiple><vline Cid="383" x="12" y="48" length="48" vertical="y"/><formattedText Cid="384" x="24" y="72" w="456" h="48"><p><p><t sz="14" b="b" fg="0xffcc00cc">MOST IMPORTANT CODE FOR THE PRACTICE</t></p><p al="2"><t b="b">- adds patient to the GSF/ End of Life register</t></p></p></formattedText><comboBox Cid="203" x="24" y="48" w="444" text="GSF Stage - possible prognosis" bias="60" amendNotes="n" blank="n" showTimeComponent="n" codes="XaZb7;XaZbA;XaZbD;XaZbE"><rc rc="XaZb7" desc=""/><rc rc="XaZbA" desc=""/><rc rc="XaZbD" desc=""/><rc rc="XaZbE" desc=""/></comboBox><checkBox Cid="88" x="24" y="180" w="420" text="Discussion/info around advance care planning" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="Xaa0j" reportDefault="-1"/><title Cid="17" x="60" y="264" width="300" text="GSF stage - Green (Months)" colour="-16737946"/><checkBox Cid="116" x="24" y="216" w="420" text="Under care of social services" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaLKF" reportDefault="-1"/><title Cid="16" x="60" y="156" width="300" text="GSF Stage - Blue (&gt;1 year)" colour="-16763956"/><checkBox Cid="144" x="516" y="324" w="432" text="Required rescue medication in place" amendNotes="n" blank="n" showTimeComponent="n" code="XaZke" reportDefault="-1"/><formattedText Cid="168" x="516" y="288" w="444" h="24"><p><p><t fnt="Arial Narrow" fg="0xff990033">NOT commissioned in all areas, though SPC/Hospice advice available for clinicians 24/7 all areas.</t></p></p></formattedText><checkBox Cid="167" x="516" y="264" w="433" text="Hospice/SPC 24hr Advice &amp; Rapid Response Service - Info provided" amendNotes="n" blank="n" showTimeComponent="n" code="XaPnl" reportDefault="-1"/><hline Cid="22" x="12" y="252" length="936"/><checkBox Cid="117" x="24" y="288" w="420" text="DS 1500 Disability living allowance completed" date="y" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="9EB5." reportDefault="-1"/><checkBox Cid="119" x="24" y="324" w="420" text="Future equipment needs considered" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="Ua02i" reportDefault="-1"/><checkBox Cid="169" x="516" y="216" w="434" text="Information around finance provided (e.g. CAB)" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="6743." reportDefault="-1"/><formattedText Cid="386" x="516" y="180" w="430" h="24"><p><p al="1"><t>( Particularly important if co-habiting)</t></p></p></formattedText><checkBox Cid="387" x="516" y="156" w="432" text="Discussion or leaflet provided re. Writing Last Will &amp; Testament" amendNotes="n" blank="n" showTimeComponent="n" code="Xag0E" reportDefault="-1"/><textarea Cid="388" x="516" y="348" w="432" h="48" text="For each Anticipated Problem document, how &amp; when to use, in the Treatment Escalation TAB"/><formattedText Cid="385" x="516" y="444" w="443" h="32"><p><p al="1"><t>(Allows a competent clinician to diagnose </t><t b="b">{ </t><t>verify </t><t b="b">}</t><t> an expected death)</t></p></p></formattedText><checkBox Cid="161" x="516" y="420" w="444" text="GP, Senior Doctor or MDT confirm imminent expected death" date="y" summary="y" level="3" problem="y" amendNotes="n" blank="n" showTimeComponent="n" code="XafjY" reportDefault="-1"/><hline Cid="205" x="12" y="384" length="936"/><title Cid="21" x="60" y="396" width="372" text="GSF stage - Yellow / Amber (Weeks)" colour="-1141200"/><checkBox Cid="81" x="24" y="420" w="420" text="NHS continuing healthcare fast track funding applied for" date="y" journal="y" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaVzx" reportDefault="-1"/><checkBox Cid="118" x="24" y="456" w="420" text="Referred to community care team for care needs or introduction" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaAQq" reportDefault="-1"/><checkBox Cid="160" x="24" y="492" w="420" text="Hospital bed, mattress &amp; continence equipment in place, if needed" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="Ub0sG" reportDefault="-1"/><hline Cid="204" x="12" y="528" length="936"/><checkBox Cid="121" x="516" y="480" w="432" text="Anticipatory medications FP10 &amp; PRN chart issued" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaPmq" reportDefault="-1"/><pageLink Cid="323" x="780" y="504" w="168" h="27" PageNumber="9" DisplayText="Anticipatory Prescribing"/><title Cid="27" x="60" y="540" width="300" text="GSF stage - Red (Days)" colour="-3407872"/><checkBox Cid="84" x="24" y="564" w="420" text="Package of care in place sufficient for needs" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="XE0p4" reportDefault="-1"/><checkBox Cid="85" x="516" y="540" w="432" text="Known to Hospice at Home / End of Life nursing team" journal="y" summary="y" level="2" amendNotes="n" blank="n" showTimeComponent="n" code="XaZLA" reportDefault="-1"/><checkBox Cid="162" x="516" y="576" w="432" text="Comm Pal Care Syringe Driver Admin Order completed" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaaD3" reportDefault="-1"/><pageLink Cid="325" x="780" y="600" w="168" h="27" PageNumber="9" DisplayText="Anticipatory Prescribing"/><formattedText Cid="419" x="24" y="612" w="456" h="26"><p><p al="1"><t sz="14" b="b" fg="0xffef3511">VERSION 3.1</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">Future Planning Template</t><t sz="14" fg="0xffef3511"> - November 2019</t></p></p></formattedText><formattedText Cid="389" x="24" y="120" w="925" h="36"><p><p al="1"><t sz="14" b="b" fg="0xffcc0066">Please record additional information in the Treatment Escalation and Future Planning TABS as appropriate.</t></p></p></formattedText><hline Cid="433" x="12" y="144" length="936"/></page><page Cid="1" name="End of Life" colour="-3342388"><hyperLink Cid="78" x="780" y="12" w="180" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><title Cid="4" x="24" y="24" width="276" text="End of Life / GSF Register"/><view Cid="390" x="24" y="396" w="930" h="202" KeyView="140609"/><notes Cid="173" x="324" y="36" w="444" h="28" text="Named accountable GP" summary="y" bias="65" amendNotes="n" blank="n" showTimeComponent="n" code="XacWQ" presetNotes=""/><notes Cid="178" x="24" y="84" w="456" h="120" text="End of Life / GSF Review - meeting notes &amp; date" date="y" summary="y" amendNotes="n" blank="n" showTimeComponent="n" code="XaLG1" orientation="Top" presetNotes=""/><textarea Cid="8" x="516" y="84" w="444" h="228" text="KARNOFSKY SCORE CRITERIA|100% - Normal; no complaints; no evidence of disease &#x9; |90% - Able to carry on normal activity; minor sign of symptoms of disease &#x9;|80% - Normal activity with effort; some signs or symptoms of disease &#x9;|70% - Cares for self; unable to carry on normal activity or to do active work |60% - Able to care for most needs; but requires occasional assistance &#x9;|50% - Considerable assistance and frequent medical care required &#x9;|40% - In bed more than 50% of the time &#x9;|30% - Almost completely bedfast &#x9;|20% - Totally bedfast and requiring extensive nursing care by professionals and/or family|10% - Comatose or barely rousable|"/><notes Cid="310" x="24" y="216" w="456" h="60" text="EoL Diagnosis or Diagnoses" summary="y" bias="65" amendNotes="n" blank="n" showTimeComponent="n" code="XaZjJ" orientation="Top" presetNotes=""/><comboBox Cid="6" x="24" y="288" w="456" text="Palliative care Phase Of Illness." journal="y" summary="y" bias="62" amendNotes="n" blank="n" showTimeComponent="n" codes="2128.;212D.;XM1UN;XaQg1"><rc rc="2128." desc=""/><rc rc="212D." desc=""/><rc rc="XM1UN" desc=""/><rc rc="XaQg1" desc=""/></comboBox><checkBox Cid="415" x="24" y="324" w="456" text="Attends Hospice Daycare or other supportive service." summary="y" amendNotes="y" blank="n" showTimeComponent="n" code="XaIt6" reportDefault="-1"/><number Cid="142" x="516" y="312" w="444" text="Australia-modified Karnofsky Performance Status scale" bias="25" amendNotes="n" blank="n" showTimeComponent="n" code="Xab0M"/><formattedText Cid="420" x="24" y="612" w="456" h="26"><p><p al="1"><t sz="14" b="b" fg="0xffef3511">VERSION 3.1</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">Future Planning Template</t><t sz="14" fg="0xffef3511"> - November 2019</t></p></p></formattedText><comboBox Cid="414" x="24" y="360" w="456" text="Hospice/specialist palliative care team involved?" summary="y" bias="40" amendNotes="y" blank="n" showTimeComponent="n" codes="XaXqW;XaXoP;XaLKI;XaIlk;XaIpa"><rc rc="XaXqW" desc=""/><rc rc="XaXoP" desc=""/><rc rc="XaLKI" desc=""/><rc rc="XaIlk" desc=""/><rc rc="XaIpa" desc=""/></comboBox></page><page Cid="326" name="Anticipatory Meds" colour="-3342388"><title Cid="332" x="24" y="12" width="276" text="Anticipatory Prescribing"/><hyperLink Cid="371" x="780" y="12" w="180" h="24" URL="www.futureplanning.org.uk" DisplayText="Future Planning Website"/><formattedText Cid="421" x="24" y="612" w="456" h="26"><p><p al="1"><t sz="14" b="b" fg="0xffef3511">VERSION 3.1</t><t sz="14" fg="0xffef3511"> of the </t><t sz="14" b="b" fg="0xffef3511">Future Planning Template</t><t sz="14" fg="0xffef3511"> - November 2019</t></p></p></formattedText><formattedText Cid="392" x="24" y="48" w="744" h="288"><p><p><t fnt="Comic Sans MS" sz="18" fg="0xffff0000">PAGE IN DEVELOPMENT</t></p><p><t fnt="Arial" sz="14" b="b">Will be released as a separate template with links from Future Planning Version 3.2. By April 2020.</t></p><p/><p><t fnt="Arial" sz="14">Please do not wait for version 3.2 before starting to use the Future Planning template. There will always be a new version sometime in the Future! Data collected in previous versions will all pull through to any new version.</t></p><p/><p><t fnt="Arial" sz="14">In response to the Report of the Gosport War Memorial Independant Panel Jan 2018, Hampshire &amp; Isle of Wight Palliative Care Physicians, working with pharmacy and GP colleagues, are aiming to develop a standard simple Anticipatory Prescribing template. This page will link to the new template and will also aid with the consistent printing or NHSmailing of the Community Syringe Driver and PRN Administration Orders used by both Solent and Southern Health community teams.</t></p><p/><p><t fnt="Arial" sz="14">Communication direct to practice managers/IT managers will take place when the new TAB and linked resources are ready for publication.</t></p></p></formattedText></page></template><Name>Future Planning GP Version 3.1</Name><Description>End of life, frailty, prognosis/GSF, TEP &amp; future planning template</Description><Category>Future Care Planning</Category><Icon>transportAmbulance</Icon><Source>132543</Source><SourceGroup>-1</SourceGroup><Position>-1j-36d1d-3k113s-21b3t19292n-t-3p-3a3h1o3g1735f-1o3u-31-1p3e2d-2s3m1d3a</Position></TemplateDefinition></SystmOneTemplates>