We need to record ACP discussions and the decisions made so that everyone has an understanding of what matters to each individual and how we can best support them and those that matter to them.
Recording Relevant Information
Most services will have their own paperwork which they use to document important conversations and decisions. For instance, social work might be aware of any home care services which are used; physiotherapy may have had a conversation about what is a realistic mobility goal; the district nurse may have spoken to the person about where they would prefer to receive end of life care. As health care professionals it is your responsibility to try and ensure your colleagues in other departments know this information.
Using the ACP summary is a good way to share this information.
You do not need to complete every part of the document. If we all take responsibility for inputting the information we have gathered in our own assessments, then this will help ensure the final ACP has all the information needed.
Which documents should I use?
Key information will be recorded in lots of different places. Your department might have their own records and documentation that they use.
The people you work with may also be using different documents to record their thoughts about Anticipatory Care Planning. They might have a “My Anticipatory Care Plan” or a ReSPECT form. There are other planning tools they might have used as well.
We can still use all these different documents. However the most important thing is key information from all of these places is recorded in the ACP summary which is available on Clinical Portal. It is your responsibility to help summarise this information and add it to the shared document.
This will ensure that your colleagues in different departments and services can access the information they need, and will also allow you to see information that other professionals have gathered.
The ACP Summary is held on Clinical Portal. For more information see “Sharing ACP Information”.
Sharing ACP Information
It is really important that this information is shared with all health and social care partners so that any treatment plans reflect people’s wishes. The easiest way to ensure that information can be accessed by everyone who needs it is through the Key Information Summary (KIS). This is an electronic record which NHS24, the Scottish Ambulance Service and hospitals can access.
To help transfer this information quickly and easily, all HSCPs in Greater Glasgow and Clyde use an ACP summary to record ACP decisions. This mirrors the information on the KIS so GPs can, if they wish, quickly copy information to the KIS. It can be accessed either on Clinical Portal (it will sit under “Care Plans” in the Clinical Documents), or services can use an interactive PDF.
If you have access to Clinical Portal you can fill out the summary directly on there. Clinical Portal will automatically send the ACP to the GP and they can, if they wish, transfer the information to the KIS.
If you do not have access to Clinical Portal you can fill out this interactive PDF and email or post a copy to the GP.
Remember, if any changes are to the ACP this information needs to be sent to the GP so they can update the KIS.