GSFS1

cnpsguid.bmp Gold Standards Framework Scotland
Palliative Care May 2009 v1.13
All Problems Records in Descending order Where MNEMONIC = "*GSFS1 "
If there is no problem listed please create one and make sure short name is *GSFS1. If there is a problem make sure it is open ( in problems book should be open for *GSFS1) before entering any data for Gold standards
<creates *GSFS1 problem> <code for jounal:On Gold standards framework: Change priority to 1>

Important information about the use of this guideline

This guideline was written to support the production of an OOH Message under the Emergency Care Summary Project in Scotland.
Before an OOH Message will be produced 3 essential steps have to be completed
1/ A Gold Standards Framework Problem must be created. If you have enabled Semi Automatic Problem generation this can be done by adding one of the history items below. If you have already created a GSFS Problem PLEASE remember to OPEN it before entering relevant data (and close it once you have finished)
All All other Clinical Data Records in Descending order Where READ_CODE = "8CM1.00 " OR READ_CODE = "ZV57C00 " OR READ_CODE = "8H7g.00 " OR READ_CODE = "8BAP.00 " OR READ_CODE = "8BAT.00 " OR READ_CODE = "8HH7.00 " OR READ_CODE = "8BJ1.00 " OR READ_CODE = "8BA2.00 " OR READ_CODE = "8H7L.00 " OR READ_CODE = "8BAS.00 " OR READ_CODE = "9EB5.00 " OR READ_CODE = "1Z01.00 " OR READ_CODE = "8H6A.00 " 638CM1.001On gold standards palliative care framework8BAP.001Specialist palliative care9EB5.001DS 1500 Disability living allowance completed8CM4.001Liverpool care pathway for the dying
2/ A Palliative Care Plan must be created including a review date
All Palliative Care Plan Records in Descending order
<Palliative Care review date for lucs and confirm if doctor likely to sign death cert>
3/ Patient Consent must be obtained and recorded in the Patient Registration Module / Consent Tab.

Section 1 Patient & Carer Details Own GP and Nurse

Last 1 Patient Details Records Last 1 Address Records All Communication numbers Records in Descending order Last 1 Other identfiers Records
Please complete the patient's consent form in Registration Module
- Select the Patient Details/Contacts tab to ensurethat Carer/Next of Kin details are up-to-date
- If Carer and Next of Kin are different both will be sentin the message. If they are the same, the information will only appear once in the message.

Section 2 Patient Medical Condition

2a Main Diagnoses (Cancer Diagnosis)

All Medical History Records in Descending order Where READ_CODE = "B"

2a Main Diagnoses (Information contained in GSFS Problem)

All Problems Records in Descending order Where MNEMONIC = "*GSFS1 "

2b Other Relevant Issues

- The Palliative Care Issues button allows you to record in freetext any issues relating to the patient's palliative care, whether it is social, medical or mental
- Only 255 characters will be shown in the OOH message
All Note Pad Records in Descending order Where TEXTTYPE = "TXT007 "
<Palliative Care Issues> Remember to change the 'Type of Note' to Palliative Care Issues
- Only 255 characters will be shown in the OOH message

2d additional drugs available at home

All Palliative Care at Home Records in Descending order
<Palliative care at home>

Section 3 Current Care Arrangements

3d Syringe Driver

All All other Clinical Data Records in Descending order Where READ_CODE = "8BC4.00 " OR READ_CODE = "8BC5.00 "
<Syringe driver commenced>

Section 4 Patient & Carer's Awareness of Condition

4a Patients Understanding of Diagnosis

Last 1 Medical History Records Where READ_CODE = "1H0..00 " OR READ_CODE = "1H1..00 "
<Patient Aware of Diagnosis> <Patient Unaware of Diagnosis>

4b Patients Understanding of Prognosis

Last 1 All other Clinical Data Records Where READ_CODE = "67D1.00 "
<Informing Patient of Prognosis>

4c Carer's Understanding of Diagnosis

Last 1 Medical History Records Where READ_CODE = "1H2..00 " OR READ_CODE = "1H3..00 "
<Family Aware of Diagnosis> <Family Unaware of Diagnosis>

4d Carer's Understanding of Prognosis

Last 1 All other Clinical Data Records Where READ_CODE = "67F1.00 "
<Informing Relative of Prognosis>

Section 5 Advice for Out of Hours Care

5c/d Should GP be contacted Out of Hours / GP Home Tel/Mobile/Pager

Last 1 OOH Arrangements (Palliative Care) Records
<should GP be contacted out of hours>

5e/f Resuscitation Status

Only the most recent entry will be shown. If Resuscitation status is unknown please record using the icon below and type unknown (plus other relevant comment ) in the comments box
Last 1 Medical History Records Where READ_CODE = "1R"
<For Resuscitation> <Not for resuscitation > <Resuscitation free text>

5h Additional Useful OOH Information

All Note Pad Records in Descending order Where TEXTTYPE = "TXT008 "
<Additional OOH Information> Remember to change the 'Type of Note' to OOH Information
- Only 255 characters will be shown in the OOH message

All Cancer Diagnoses

All Medical History Records in Descending order Where READ_CODE = "B"
Please ensure that the CURRENT diagnosis and any RELEVANT operations are recorded and linked to the Problem Header of Gold Standards Framework Scotland - Palliative Care in order that they are included in the OOH Message.

Preferred Place of Care / Death (Also see Section 5)

All Patient Preference Records in Descending order Where READ_CODE = "94Z"
<home> <Nursing home> <Community hospital> <hospital> <hospice>

Palliative Care Data Summary (Information included in the GSFS Problem)

A summary of Palliative Care Data can be found linked to the Problem entitled "Gold Standards Framework Scotland - Palliative Care" which was created when you first used this guideline.
All Problems Records in Descending order Where MNEMONIC = "*GSFS1 "