CHIPP Care Home Plan Gateshead V1 0 EMIS LV Sept 2011 by R4fQpPOC

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									                           CARE HOME INDIVIDUAL PATIENT PLAN (CHIPP)

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Please FAX a copy of this form to GATDOC – 0191 4455463
Please ensure a copy is left at the CAREHOME.

Click here for Gateshead Primary Care Care Home review Guidance V5 (Sept 2010)

To complete this form ensure the form is locked (see typed instructions above). Use the
tab key to complete the compulsory yellow/red drop down menus and add in any relevant
information to yellow text boxes below.

DATE OF THIS PLAN                                          REVIEW DATE:
LEAD GP:                                                   OSPN:
GP Surgery:                   ~[Surgery Address Line 1]
                              ~[Surgery Address Line 2]
                              ~[Surgery Address Line 3]
                              ~[Surgery Address Line 4]
                              ~[Surgery Address Line 5]


                                             PATIENT DETAILS
Name           ~[Title] ~[Forename] ~[Surname]                Previous Name           ~[Previous
                                                                                      Name]

DoB            ~[Date Of     AGE:       ~[Patie   Gender      ~[Sex]    NHS Number    ~[NHS Number]
               Birth]                   nts
                                        Age]

Address        ~[Patient Address Block]                       Telephone         Home: ~[Telephone
               ~[Post Code]                                                     Number]
                                                                                Work: ~[Work]
                                                                                Mobile: ~[Mobile]


MAIN CONTACT (eg Family member or Friend)
Name Of Contact                                      Relationship to Patient

Contact Tel numbers

CARE HOME INFORMATION
Category of Care:            Please Select                    Date of Admission to
                                                              Care Home:

                                           MEDICAL CONDITIONS

Medical History:
~[Active Problems:AS~AM~PS~FT]

Current Medication:
~[Medication]

Allergies:
~[Allergies]
 ~[Title] ~[Forename] ~[Surname]          ~[Date Of Birth]     ~[NHS Number]               Page 2 of 2



                                       ANTICIPATORY PLANNING

To promote health/well being/reduce admission risk
KNOWN PROBLEMS:                               MANAGEMENT PLAN:

Aiming for early recognition of deterioration
ANTICIPATED PROBLEMS:                                  SUGGESTED MANAGEMENT PLAN:

                                      END OF LIFE CARE ISSUES

CARE PLANNING IN PLACE                    YES NO        DETAILS
Advanced Care Plan
Preferred Place of Care
DNAR
Advanced Decision to refuse
treatment
Mental Capacity Assessment
Deprivation of Liberty
Assessment
Best Interest Decisions

                                            COMMUNICATION

Professionals Involved:
ROLE                        NAME                                     CONTACT DETAILS
OPSN
Lead GP
Community Matron
District Nurse
                                        Other please state below


Care Plan agreed with:

Patient
Yes No        Details of Discussion/Comments


Family/Friend
Yes No Name/s                    Relationship      Contact Details   Details of Discussion/Comments


Care Home Staff
Yes No Name/s                    Role              Contact Details   Details of Discussion/Comments


CHIPP completed by: (Print name) ……………………………………..
Base/Surgery: …………………………………………………………………
Signed: ………………………………………….. Date: ……………………

(CHIPP Care Home Plan Gateshead V1.O EMIS LV September 2011)

								
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