TEMPLATE End of Life Care Coordination Document - Leeds EPCCS (Composition) (End of Life Care Coordination Document - Leeds EPCCS (Composition))

TEMPLATE ID	End of Life Care Coordination Document - Leeds EPCCS (Composition)
Concept	End of Life Care Coordination Document - Leeds EPCCS (Composition)
Description	To record the details of an End of Life Care Coordination document based on the dataset developed by the Leeds EPaCCS team and aligned with the ISB.
Purpose	To record the details of an End of Life Care Coordination document based on the dataset developed by the Leeds EPaCCS team and aligned with the ISB.
References
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set
Language used	en
Citeable Identifier	1013.26.571
Root archetype id	openEHR-EHR-COMPOSITION.care_plan.v1
End of Life Care Coordination Document (LEPCCS)	End of Life Care Coordination Document (LEPCCS): unknown
Clinical author
End of life care register	End of life care register: Details of registration on an end of life care register.
Registration status	Registration status: The patient's registration status. On end of life care register Not suitable for end of life care register
Date register status last updated	Date register status last updated: The date at which the end of life care register status was last updated.
Planned review date	Planned review date: The date at which the end of life care register record should be reviewed.
Comment	Comment: Any additional comment.
Consent to share information	Consent to share information: Details of the subject's wishes and consent with respect to sharing their care record, particularly their GP record.
Consent to share status	Consent to share status: The consent status for the shared record service or project identified. Declined consent to share patient data with specified third party Consent withdrawn to share patient data with specified third party Consent for electronic palliative care upload Dissent for electronic palliative care upload
Date last updated	Date last updated: The date at which the consent status was last updated.
Key contacts	Key contacts: Key contacts for the patient or client, including formal and informal carers, next of kin and key workers.
Nominated main carer	Nominated main carer: An individual identified by the person as offering care and support , excluding paid carers or carers from voluntary agencies.
Nominated main carer	Nominated main carer: Personal demographics including name(s) , addresse(s) and telecommunication contact details.
Person name	Person name: Details of personal name of an individual, provider or third party.
Carer name	Carer name: Name in free text unstructured format.
Address	Address: To record details of one or more personal addresses.
Address	Address: One or more adresses for an individual.
Address Type	Address Type: The type of address. Residential
Unstructured address	Unstructured address: A postal address expressed in an unstructured format. ENV 13606 - 4:2000 7.11.15.
Telephone number 1	Telephone number 1: Personal or organisational telecommunication details, including telephone, fax, and email or other telecommunications details e.g skype address.
Unstuctured telcoms	Unstuctured telcoms: An unstructured description of telecoms.
Telephone number 2	Telephone number 2: Personal or organisational telecommunication details, including telephone, fax, and email or other telecommunications details e.g skype address.
Unstuctured telcoms	Unstuctured telcoms: An unstructured description of telecoms.
Is nominated main carer?	Is nominated main carer?: True if the individual , excluding paid carers or carers from voluntary agencies, is identified by the subject as being a primary source of care and support. Default value: true
Next of kin	Next of kin: An individual identified by the person as offering care and support , excluding paid carers or carers from voluntary agencies.
Next of kin	Next of kin: Personal demographics including name(s) , addresse(s) and telecommunication contact details.
Person name	Person name: Details of personal name of an individual, provider or third party.
Next of kin name	Next of kin name: Name in free text unstructured format.
Next of kin telephone number 1	Next of kin telephone number 1: Personal or organisational telecommunication details, including telephone, fax, and email or other telecommunications details e.g skype address.
Unstuctured telcoms	Unstuctured telcoms: An unstructured description of telecoms.
Next of kin telephone number 2	Next of kin telephone number 2: Personal or organisational telecommunication details, including telephone, fax, and email or other telecommunications details e.g skype address.
Unstuctured telcoms	Unstuctured telcoms: An unstructured description of telecoms.
Is next of kin?	Is next of kin?: True if this informal care is the person's next-of-kin. Default value: true
Formal carer	Formal carer: A health and social care professional or staff member, including a carer from voluntary sector.
Individual professional demographics (UK)	Individual professional demographics (UK): Professional demographics details including name(s) , addresse(s) and telecommunication contact details.
Person name	Person name: Details of personal name of an individual, provider or third party.
Unstructured name	Unstructured name: Name in free text unstructured format.
Telecom details (UK)	Telecom details (UK): Personal or organisational telecommunication details, including telephone, fax, and email or other telecommunications details e.g skype address.
Unstuctured telcoms	Unstuctured telcoms: An unstructured description of telecoms.
Professional group	Professional group: The speciality of the carer.
Is key worker?	Is key worker?: True if the formal carer is the subject's key worker?
Note	Note: Any additional comment or note about the carer or their role.
Date updated	Date updated: The date at which the list of key contacts was created or updated.
Problems and diagnoses	Problems and diagnoses: unknown
Main diagnosis	Main diagnosis: *
Main diagnosis	Main diagnosis: Identification of the index problem, issue or diagnosis.
Description	Description: A narrative description of the issue, problem or diagnosis.
Date of Onset	Date of Onset: The date / time when the problem was first identified by the individual.
Main carer insight	Main carer insight: Is the main informal carer aware of the patient's prognosis? Carer has insight of patients illness Relative aware of prognosis Relative unaware of prognosis Carer aware of prognosis Carer unaware of prognosis
Patient insight	Patient insight: Does the patient have insight into their illness and/or prognosis? Patient has insight of their illness Patiient aware of prognosis Patient not aware of prognosis
Date last updated	Date last updated: The date that the prognosis was made or last updated.
Other issues	Other issues: *
Problem/Diagnosis	Problem/Diagnosis: An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose and inclusive of a formal biomedical diagnosis so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree.
Other relevant issue	Other relevant issue: Identification of the index problem, issue or diagnosis.
Description	Description: A narrative description of the issue, problem or diagnosis.
Date of Onset	Date of Onset: The date / time when the problem was first identified by the individual.
Allergies	Allergies: RCP Allergies Heading.
Allergies list	Allergies list: A list of individual structured allergy records.
Adverse reaction	Adverse reaction: Details of a harmful or undesirable effect, including allergy and intolerance, associated with known or suspected exposure to a drug or other medicinal substance.
Causative agent	Causative agent: Details of the agent or medicinal substance believed to be the cause of the adverse reaction or allergy. For GP2GP V2 use, it is currently anticipated that there will be 4 permissible ways to express a Causative agent: Drug Group (SNOMED-CT), dm+d VMP/AMP (dm+d), Ingredient (SNOMED-CT), TradeFamily/TradeFamilyGroup (SNOMED-CT). It is MANDATORY that one and only one of these must always be selected. Optionally, in addition a SNOMED AllergyCode may be sent as a mapping, but can never be sent on its own. For legacy use other codes are permissible such as FDB Agent codes, EMIS Drug codes and READ codes but these should be carried as simple free text and the coded information carried in mappings/translation attributes. This kind of coding is not regarded as being safe to trigger decision support outwith the native GP system. The exact subset definitions have not yet been agreed and may change prior to full implementation. Coded Text Value set: terminology:SNOMED-CT?subset=CausativeAgents Text
Reaction details	Reaction details: Details of a single reaction thought to be due to the causative agent.
Date recorded	Date recorded: The date that the reaction was clinically recorded/asserted. This will often equate to the date of onset of the reaction but this may not be wholly clear from source data. From Welsh IHR / openHR model.
Comment	Comment: Any additional comment or clarification about the adverse reaction. From Welsh IHR model
Exclusion of an Adverse Reaction	Exclusion of an Adverse Reaction: Positive statement/s about adverse reactions that need to be recorded as clinically excluded from the health record at a specific point in time.
Data
Exclusion Statement	Exclusion Statement: A statement about exclusion of known adverse reactions in the health record. For example: "No known adverse reactions"; "No known adverse reaction to" (penicillin).
Comment	Comment: Additional narrative about the Exclusion not captured in other fields.
Date Last Updated	Date Last Updated: The date at which the exclusion was last clinically asserted, affirmed or confirmed.
Contraindication	Contraindication: Identification of a treatment, medicine, vaccine or procedure which should not be administered or performed on this subject.
Contraindication	Contraindication: Identified contraindication to a treatment, medicine, vaccine or procedure. Coding of the identified Contraindication with a terminology is desirable, where possible.
Evidence/Rationale	Evidence/Rationale: Evidence or rationale for the contraindication. This should be explicitly stated, so that this rationale can be explicit if this data is shared in a message or with another clinical system, although an optional link to evidence within the same record is also permitted.
Date Last Updated	Date Last Updated: The date at which the contraindication was most recently deemed to apply, normally as a result of clinical assertion or affirmation.
Medications	Medications: RCP Medication Heading structure.
Current medication	Current medication: Medication being currently taken by the patient.
Medication summary entry	Medication summary entry: Record of a single medication item, either to record the current medication order, or for summary purposes in clinical communications, including information on past issues, authorisations, dispensing and administration. Annotations Notes.Authors Note: Authors other note GUI Directives.Widget Type: Text Box GUI Directives.Show Description: true
guideline_id
other_participations
workflow_id
expiry_time
narrative
wf_definition
Medication item	Medication item: Records details of a medication product, dosage and administration directions, for use within medication recommendation, order, administration and dispensation records.
Medication name	Medication name: Mandatory medication name coded using a SNOMEDCT/dm+d term where possible, allowing plain text for historical/patient reported items , extemporaneous preparations or those not registered in dm+d. e.g.“Citalopram tab 20mg”, "Trimethoprim" Text Coded Text Value set: terminology:dm%2Bd?subset=NHS_dm%2Bd
Form	Form: Form of the medicinal substance e.g capsules, tablets, liquid. Not normally required unless a specific form has been requested by the prescriber. e.g. "Modified Release Capsules" Value set: terminology:SNOMED-CT?subset=CFH%3A%3ADoseForm
Dose directions description	Dose directions description: A single plain text phrase describing the entire medication dosage and administration directions, including dose quantity and medication frequency. e.g. “I tablet at night” or “20mg at 10pm”
Anticipatory medication	Anticipatory medication: A clinical activity that has been carried out for therapeutic or diagnostic purposes.
Description
Anticipatory medication	Anticipatory medication: The name of the procedure. Issue of palliative care anticipatory medication box
Anticipatory medication location	Anticipatory medication location: Comments about the procedure.
Advance Care Plan	Advance Care Plan: A generic section header.
Healthcare funding status (UK)	Healthcare funding status (UK): The patient's current status with respect to healthcare funding arrangements.
Healthcare funding status	Healthcare funding status: The status of the patient's ongoing continuing healthcare funding. Continuing healthcare funding in place Continuing healthcare funding refused
Fast-track healthcare funding status	Fast-track healthcare funding status: The status of the patient's fast-track healthcare funding arrangements. Continuing healthcare fast track funding granted Continuing healthcare fast track funding refused
Date last updated	Date last updated: The date at which the healthcare funding status was last updated.
Carer Needs Assessment	Carer Needs Assessment: Activity regarding a referral from a clinician, or self-referral by a patient, for the patient to receive a specific service, advice or care from an expert healthcare provider.
Referred service	Referred service: Identification of the clinical service to be/being carried out. This is often coded with an external terminology. Carer Needs Assessment Default value: Carer Needs Assessment
Description	Description: Description of the service provided.
Advanced care planning	Advanced care planning: Care planning and pathway aspects of an End of Life Care Coordination record.
Care pathway status	Care pathway status: The status of advanced care planning. Has end of life advanced care plan Discussion about advance care plan
End of life tool	End of life tool: The use, or otherwise of a specific end of life pathway tool. On Liverpool care pathway for the dying Liverpool Care Pathway declined On gold standards palliative care framework End of Life tool not used
Care staging	Care staging: The estimated stage of clinical care, slected from the GSF categories or via free text. Gold standards framework supportive care stage 1 - advancing disease Gold standards framework supportive care stage 2 - increasing decline Gold standards framework supportive care stage 3 - last days: category B - months prognosis Gold standards framework supportive care stage 3 - last days: category C - weeks prognosis Gold standards framework supportive care stage 3 - last days: category D - days prognosis
Date last updated	Date last updated: The date at which the advanced care plan status was last updated.
Preferred priorities of care	Preferred priorities of care: The subject's preferred priorities of care and special requests.
Preferred place of care	Preferred place of care: The patient's preferred place of care (first choice). Preferred place of care - home Preferred place of care - hospice Preferred place of care - community hospital Preferred place of care - hospital Preferred place of care - nursing home Preferred place of care - residential home Preferred place of care - patient declined to participate Preferred place of care - discussion not appropriate Preferred place of care - patient unable to express preference
(Preferred place of care location)	(Preferred place of care location): Details of the organisation/location of the preferred place of care.
Preferred place of death	Preferred place of death: The patient's first choice preferred place of death. Preferred place of death: home Preferred place of death: hospice Preferred place of death: community hospital Preferred place of death: hospital Preferred place of death: nursing home Preferred place of death: residential home Preferred place of death: patient unable to express preference Preferred place of death discussed with patient Preferred place of death: discussion not appropriate Preferred place of death: patient undecided Preferred place of death: patient declined discussion Preferred place of death: usual place of residence
(Preferred place of death location)	(Preferred place of death location): Details of the organisation/location of the preferred place of death.
Personal request or preference	Personal request or preference: Any other specifc personal request or preference, including cultural or religious preferences.
Comment	Comment: Any additional comments about the subject's place of care preferences.
Power of attorney (UK)	Power of attorney (UK): Details of power of attorney arrangements specific to the UK.
Date last updated	Date last updated: The date that the record of power of attorney was last updated.
Mental capacity status	Mental capacity status: Patient's ability to make informed choices in terms of the Mental Capacity Act 2005.
Lasting power of attorney for personal welfare	Lasting power of attorney for personal welfare: Details of lasting power of attorney for Personal Welfare.
Power of attorney status	Power of attorney status: The status of any lasting power of attorney. Lasting power of attorney personal welfare.
Person holding power of attorney	Person holding power of attorney: Details of the person holding power of attorney for personal welfare.
Lasting power of attorney for property and affairs	Lasting power of attorney for property and affairs: Details of lasting power of attorney for property and affairs.
Power of attorney status	Power of attorney status: Status of lasting pwer of attorney for property and affairs. Lasting power of attorney property and affairs
Person holding power of attorney	Person holding power of attorney: Details of the person holding power of attorney for property and affairs.
Other person to be involved in decision-making	Other person to be involved in decision-making: Details of any other person who the patient wishes to be involved in decision-making.
Advance decision to refuse treatment	Advance decision to refuse treatment: An advance decision to refuse treatment (ADRT) is a decision to refuse a specific treatment, made in advance by a person who has capacity to do so.
Decision status	Decision status: The state of the decision to refuse treatment. Advanced decision to refuse treatment signed Has advance decision to refuse treatment (Mental Capacity Act 2005) Has advance decision to refuse life sustaining treatment (Mental Capacity Act 2005) Advanced directive not signed
Date of decision	Date of decision: The date at which the DNACPR decision was originally taken or last reviewed.
Comment	Comment: Other narrative comment pertinent to the advanced directive.
Location of advance directive documentation	Location of advance directive documentation: The location of the original advanced directive document, either a text description or an electronic link. Text URI
CPR decision	CPR decision: The outcome of a clinical decision as to whether cardio-pulmonary resuscitation should be undertaken or not. This is generally referred to in UK clinical guidance as the CPR (Cardio-pulmonary resuscitation) decision.
CPR decision	CPR decision: The clinical decision on whether cardiopulmonary resuscitation (CPR) should be attempted. In some cases a clear answer may not be available to the recording clinician. For attempted cardio-pulmonary resuscitation Not for attempted cardiopulmonary resuscitation CPR decision status unknown
Date of CPR decision	Date of CPR decision: The date at which the CPR decision was originally taken or last reviewed.
Comment	Comment: Other narrative comment pertinent to the CPR decision.
CPR form completed	CPR form completed: Has the physical CPR form been completed? CPR form completed CPR form not completed
Discussion with patient	Discussion with patient: Has resuscitation been discussed with the patient? Resuscitation discussed with patient Resucitation not discussed with patient
Discussion with family	Discussion with family: Has resuscitation been discussed with the patient's informal carer or carers? Resuscitation discussed with informal carer Resuscitation not discussed with informal carer
Location of CPR documentation	Location of CPR documentation: The location of the original CPR document, either a text description or an electronic link. Text URI
Date for review of CPR decision	Date for review of CPR decision: The date at which the CPR decision should be reviewed.
Other	Other: A generic section header.
Referral activity (UK)	Referral activity (UK): Activity regarding a referral from a clinician, or self-referral by a patient, for the patient to receive a specific service, advice or care from an expert healthcare provider.
MDT Meeting	MDT Meeting: Identification of the clinical service to be/being carried out. This is often coded with an external terminology. Terminology: SNOMED-CT multidisciplinary care conference
Service type	Service type: Type of service to be carried out or being carried out. Multidisciplinary case conference Individual programme planning meeting
Description	Description: Description of the service provided.
Place of death (UK)	Place of death (UK): The location at which the subject died and any variance from their preferred place of death.
Place of death	Place of death: The place at which the patient died. Patient died at home Patient died in hospice Patient died in community hospital Patient died in hospital Patient died in nursing home Patient died in care home Patient died in residential institution NOS
Location details	Location details: Details of the organisation or location at which the patient died.
Variance from preference	Variance from preference: Details of the extent to which the patient's place of death varied from their expressed preference.
Achievement of preference	Achievement of preference: Did the person achieve their preferred place of death? First choice place of death achieved Choice of place of death not achieved
Reason for variance	Reason for variance: The reason why the patient's choice of death was not achieved.

TEMPLATE End of Life Care Coordination Document - Leeds EPCCS (Composition) (End of Life Care Coordination Document - Leeds EPCCS (Composition))

Annotations