Anticipatory Care Planning: Frequently Asked Questions
To provide practical support and guidance on long term condition anticipatory care plans.
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
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
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