Database Entry ID Number.
Tick Primary Care Trust / Sunderland / / South Tyneside / / Gateshead /
Professional Completing Form > / Name:
Job Title:
Location Review Completed
Patients Home / Hospice / GP Practice/Health Centre
Care Home / Other (Please Specify)
GP DETAILS / PATIENT DETAILS
GP Name / NHS Number
GP / Date of Birth
Address / Gender / M / / F /
GP Postcode / Diagnosis Update
REVIEWADVANCE CARE PLANNING DETAILS
Date of Review
Is there achange to lasting power of Attorney LPA / Yes / / No /
Please tick below who was included in the Discussion
/ Family / Notes
/ Carer / Notes
DISCUSSION OF PREFERENCES/CHOICES / Date Discussed
Discussion of Preferences/choices / Yes / / No /
Tick if included in the discussion / Care Now / / Care in the Future / / Place of Death /
Other Aspects of Discussion
Date Discussed
Alternative Preferences/choices Discussed? / Yes / / No /
Any changes to the previous plan? / Yes / / No /
REVIEW DATES
Date Agreed / Yes / / No / / State Review Date
REVIEW SHARED WITH
Please tick all the areas below the advance care planning has been shared with
GP / / Primecare/GatDoc/NorDoc / / Hospital Inpatient /
Out Patient / / Hospice Inpatient / / Day Care /
Care Home / / District Nurse / / 24/7 Team /
Urgent Care Team / / Social Services / / Community Matron /
Marie Curie / / Key Worker /
Palliative Care Specialist Nurse / / Or Other Specialist Nurse (Please Detail below) /
Overnight Palliative Care Team / Over Night Nursing Team /
THANK YOU PLEASE RETURN TO
Palliative Care Team Secretary, St Benedicts Hospice , Sunderland, Fax 0191 5699253