PERSONALISED PLAN AND EMERGENCY CARE PLAN FOR	
Title Calling Name Surname	

The information included in this care plan is correct as Short date letter merged and should be used as a guide thereafter in your clinical assessment. If any significant changes develop after this date please discuss with the relevant health professional involved in your care.

The purpose of this document is to give you the opportunity to let your doctor and health care team know about your priorities and preferences for your healthcare and how you would choose to be looked after in the future. 

•	The first section is helpful should an emergency ever happen.

•	The second section records your own plans for living with your health conditions.

Please keep this document somewhere prominent in your house for use in an emergency.

IF YOU ARE UNWELL AND NEED ADVICE OR SUPPORT 	
	
If you are unwell	
During office hours
GP practice	Organisation Telephone Number	
Out of hours contact 
CHoC direct	0300 30 34 365	

For any other queries, advice or support (during office hours)	
Single Code Entry: Name of care coordinator  	Free Text Prompt	

In an emergency who would you like us to contact?
Name 	Contact number	
Emergency contact  	Single Code Entry: Emergency contact details  	
Next of Kin (if different)	Single Code Entry: Patient's next of kin  	
Carer details (if appropriate) 	Single Code Entry: Carer's details  	

KEY INFORMATION SUMMARY	
	
WHAT YOU WOULD LIKE PEOPLE TO KNOW ABOUT YOU	
Single Code Entry: Patient narrative   

WHAT IS IMPORTANT TO YOU IN AN EMERGENCY SITUATION	
Single Code Entry: Advance care planning

SUMMARY FROM GP RECORD	
Problems 

ALLERGIES	
Allergies 

MEDICAL SUMMARY (including what normal looks like)	
Single Code Entry: Professional narrative  

		EMERGENCY CARE PLAN	
	
INFORMATION FOR PROFESSIONALS 	
Full name:    Title Given Name Surname 
Known as:   Calling Name 	NHS number:  NHS Number 	
	Date of birth:   Date of Birth 	
Telephone numbers: 	
 Home:  Patient Home Telephone 
 Mobile: Patient Mobile Telephone 
 Work:   Patient Work Telephone 	Key safe/door access code:
Single Code Entry: Patient door access key code  	
Communication needs: 
Single Code Entry: Difficulty communicating  Single Code Entry: Uses British sign language...    Single Code Entry: Using Makaton sign language  Single Code Entry: Uses symbols for communication  Single Code Entry: Able to use picture exchange for communication  Single Code Entry: Uses alternative communication skill  	
Language:  
Main Language	Interpreter needed:  
Single Code Entry: Interpreter needed	
Dependants:  
Single Code Entry: Number of dependants	Pets:   
Single Code Entry: Pet ownership - finding...	
Capacity:  
Single Code Entry: Impaired cognition	
GP Practice: 
Organisation Full Address (single line)	
	
GUIDE FOR FUTURE CARE & EMERGENCY DECISIONS	
DNACPR:  	Single Code Entry: Not for resuscitation...	
CPR discussed: 	Single Code Entry: Discussion about resuscitation...
Single Code Entry: Discussion about resuscitation with carer  	
LPA (Health & Welfare):	Single Code Entry: Lasting power of attorney personal welfare	
Deprivation of Liberty (DoLs) in place:	Single Code Entry: Standard authorisation for deprivation of liberty under Mental Capacity Act 2005 given	
Advanced Decision to Refuse Treatment (ADRT):	Single Code Entry: Has ADRT (advance decision to refuse treatment) (Mental Capacity Act 2005)	
Emergency Health Care Plan (EHCP):	Single Code Entry: Emergency health care plan  	
Preferred place of care:	Single Code Entry: Preferred place of care - home... 
Single Code Entry: Preferred place of death: home...  	
On palliative care register:	 Single Code Entry: On palliative care register  	

WHAT TO DO IF YOUR HEALTH SUDDENLY GETS WORSE	
	
Health issue:	
	
What symptoms or changes should you look for?	

What actions do you take?	
	
Contact person and number if you need this:	

Health issue:	
	
What symptoms or changes should you look for?	
	
What actions do you take?	
	
Contact person and number if you need this:	

PERSONAL PLAN	

What issues are important to me or what I want to work on:	
Single Code Entry: Identifying goals 	

Personal plan	

What my key professional contact will organise for me:	
Single Code Entry: Agreeing on health professional actions in care plan

Referral made to:
Single Code Entry: Referral needed	
	
My plan was completed with:	Review of plan:	
	
Diary Entries