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Guidance Notes for Clinical Portal

These guidance notes refer to different parts of the ACP Summary on Clinical Portal.

Consent

We do not require explicit consent to share the information contained within the ACP. Therefore the ACP Summary no longer records if someone has given consent to have an ACP.

An ACP is a document brings many pieces of information together into a shareable format. Therefore by engaging in an ACP conversation, the individual (or legal guardian) is agreeing to share this information.

Article 6(1)(e) of the UKGDPR in conjunction with the Intra NHS Scotland Sharing Accord allow the information contained within this document to be shared with Primary Care and other NHS Boards including NHS 24 and Scottish Ambulance, without the need for explicit consent. We are sharing this information for routine patient care as part of our Board’s duty to provide healthcare to our patients. It is best practice for staff to make sure the individual and/or their legal proxy is aware this information will be shared when conducting ACP conversations. If the patient would like further information about how the Board uses their data it can be found in our Privacy Notice here – https://www.nhsggc.org.uk/patients-and-visitors/faqs/data-protection-privacy/#

Recording whether someone would like to share information via ACP

Although we no longer record consent on the ACP Summary, the summary does include a question about whether or not an individual (or their legal guardian) wishes to have an ACP.

By asking this question we hope to enable staff to evidence when a conversation takes place, but the offer of an ACP is declined. We will monitor this data.

If an ACP is refused, staff have the opportunity to record the reason for this. We would ask all staff to complete this in order to provide context to their colleagues who may wish to revisit the conversation at a later date.

Clinical Frailty Score (Rockwood)

We would encourage all staff to consider carrying out a Rockwood Frailty Assessment and select the appropriate score in the ACP Summary.

If a frailty assessment is not applicable please select “0 – Not Applicable”.

Frailty Score Guidance (you can also download an app – Clinical Frailty Scale (CFS) – to help with the assessment – download for apple or android).

Diagram of Clinical Frailty Scale
Special Notes / What is important to the individual?

Overview of person including family circumstances, accommodation information, health goals, what matters to them, emergency planning information etc. If person is a carer, or has informal carers please state too.

If person lacks capacity ensure this is recorded alongside who has been present during any discussions.

If a person declines an ACP, staff are encouraged to ask permission to record this decision on the ACP Summary so that other services are aware that an ACP has been offered. It is also best practice to indicate whether the person may be willing to revisit these conversations at a later date. Please record this in the appropriate question.

Current Health Problems / Significant Diagnoses

Overview of health issues and diagnoses. Baseline functional and clinical status to help clinician identify deterioration – e.g. baseline O2%, 6-CIT score, level of mobility, current or planned treatments.

It is good practice to indicate if there are any treatments or interventions that the person would not wish. If they have an Advanced Directive this can be indicated.

My preferred place of care

Depending on the person’s own circumstance and health journey, this may include preference about:

  • long term care (e.g. nursing or residential care)
  • place of treatment. This could include short or long term treatment.
  • place of death

This section may also include the current level of care being provided by informal carers and/or any discussions which have occurred regarding on going and future care they may be able to provide.

My views about hospital admission / views about treatments and interventions / family agreement

It is best practice to give as much information as possible regarding views about hospital admission and explore with people what might happen in different scenarios. For example people may be willing to be admitted for a short period for symptom management, however would be unwilling to be admitted if it was likely they would be in hospital for long periods.

For people who are frail, in residential/nursing homes or approaching the end of their lives, it may be useful to discuss the 3 following scenarios:

  1. If you had a sudden illness (such as a stroke or a heart condition), how do you think you would like
    to be cared for?
  2. If you had a serious infection that was not improving with treatments we can give in the community like antibiotic tablets or syrup, how do you think you would like to be cared for?
  3. If you were not eating or drinking because you were now very unwell, how do you think you would like to be cared for?