National information standard summary data items

This is a summary of the data items included in the national information standard Palliative Care Co-ordination: core content (SCCI1580). For details please see the Palliative Care Co-ordination Requirements specification.

1. Consent 
  Consent Status*
2. Record creation* date and record amendment* dates
3. Plan and requested actions
  Planned review date
  Cardiopulmonary Resuscitation Decision – whether a decision has been made, the decision, date of decision, location of the documentation and date for review
 4. Person Demographics
  Person Name*, including preferred name
  Date of birth*
  Person address*
  NHS number* and NHS number indicator code*
  Person telephone number
  Relevant contacts
  Main carer name and contact details
  Availability of carer support*
5. Special requirements
  Need for interpreter
  Preferred spoken language
  Functional status
  End of Life Care Tools in use eg Gold Standards Framework
6. Information and advice given
  Is main carer aware of person's prognosis?
  Is person aware of the cardiopulmonary resuscitation clinical decision?
  Family member/carer informed of cardiopulmonary resuscitation clinical decision?
7. GP Practice
  GP Name*
  GP Practice details*
8. Key worker
  Telephone number
9. Services and care
  Names of health and social care staff and professionals involved in care
  Professional group
  Telephone number
10. Diagnoses
  Primary end of life care diagnosis*
  Other relevant end of life care diagnoses and clinical issues
  Allergies or adverse drug reactions
  Likely prognosis
11. Allergies or adverse reactions
12. Medications and medical devices
  Whether a 'just in case box' or anticipatory medicines have been prescribed 
  Where these medicines are kept
13. Legal information
  Advance statement
  Requests or preferences that have been stated
  Advance Decision to Refuse Treatment (ADRT)
  Whether a decision has been made, the decision, date of decision and the location of the documentation
  Lasting Power of Attorney or similar
  Name and contact details of person appointed with Lasting Power of Attorney (LPA) for personal welfare
      without authority to make life-sustaining decisions
      with authority to make life-sustaining decisions
14. Person and carer's concerns, expectations and wishes
  Preferred place of death 1st and 2nd choices if made
  Names and contact details of others (1 and 2) that the person wants to be involved in decisions about their care
15. Actual place of death
16. Date of death

*Completion of these items is mandatory.

Related links

National Information Standard (SCCI1580)

Palliative Care Co-ordination Implementation guidance

Palliative Care Co-ordination Record keeping guidance

Palliative Care Co-ordination Summary record keeping guidance

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