Northamptonshire GP Out Of Hours
NHS 111
ICT
Primecare
SPECIAL PATIENT NOTE (SPN) v2.0
Complete relevant sections as fully and clearly as possible (Typed/Block Capitals) to ensure this form can be processed.
In particular the Patient’s Name, NHS number and DOB are essential to correctly identify/match the patient.
● Please attempt to provide contact details of relevant services/professionals that might also be available out of hours.
● Please inform us when the patient has died or no longer has specific needs.
Important: Consent should be sought from the patient (or parents/guardian/carer if patient lacks capacity to consent) to
share the information included in any Special Patient Note. If consent cannot be obtained, then any Special Patient Note
should only be created if judged to be in the patient’s best interest and/or to protect others (in line with professional
Guidance and Duty of Care). In cases of doubt, you may wish to seek guidance from your Caldicott Guardian.
Please ensure the Declaration at the end of this form is carefully read and completed.
GP
PATIENT
Patient’s Surname:
Patient’s Forename:
Patient’s DOB:
/
Patient’s Gender:
Patient’s Telephone:
Patient’s Mobile:
NHS Number:
Patient’s Address:
Next of Kin Details
Carer Details
GP Name:
Practice Address:
Practice’s Telephone:
Practice’s NHS Mail:
Current
Medication
Details:
Known
Allergies
Details:
Diagnosis if
known
Details:
/
@nhs.net
Specific
Management Eg. Regarding pain, vomiting, breathlessness etc.
Plan
CHILD
AT RISK
Nature of Risk:
Physical
ADULT
Neglect
Details:
Name of Key Professional:
Nature of Vulnerability:
VULNERABLE
Emotional
Dementia
Learning Difficulties
Details:
Name of Key Professional:
Carer’s Name:
LONG
Nature of Risk:
Details:
Violence
Local Authority:
Contact Details:
Domestic Violence
Other
Contact Details:
Carer’s Telephone:
Carer’s Mobile:
Carer’s Relationship to Patient:
HEALTHCARE
WORKER
AT RISK
Other
Location
Any special procedure to follow?
Dangerous Animal
Other
Please Select
Details: (e.g. diagnosis/care plan/ admission avoidance plans/dementia/learning difficulties/contact details for
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Northamptonshire GP Out Of Hours
TERM
CONDITION
NHS 111
MISUSE
Primecare
appropriate services if patient’s condition deteriorates/any specific location for conveyance)
Name of Key Worker/ and
role:
SUBSTANCE
ICT
Contact Details:
Details: e.g. i) Drugs / Alcohol being abused ii) Any known Drug seeking behaviour (including drugs to avoid
prescribing) iii) Any Drugs being prescribed and Management Plan
Under care of substance
misuse service?
Yes – contact details:
No
FREQUENT Details & Specific Management Plan: e.g. guidance on managing specific health anxiety
CALLER
MENTAL
HEALTH
Details: (e.g. diagnosis/care plan/crisis plan/features of relapse)
Has the patient had a full mental capacity assessment?
No
Yes - if yes Date :
/ /
Any history of self-harm or attempted suicide?
No
Yes – include any details above
Previously or currently detained under Mental Health Act?
No
Yes – include any details above
Keyworker/Care Coordinator:
Contact Details:
Lead Mental Health
Contact Details:
Professional:
Crisis Team Contact Number:
COMMUN
-ICATION
BARRIER
Limited/No English – specific language spoken:
Details:
ACCESS
INFO
Speech
Hearing
Other
Via Friend, Family Member or Neighbour - Contact Details:
Via Keysafe – instructions/code:
Other – specify:
Is the patient on a GSF/Palliative Care Register?
Is the patient expected to die within two weeks?
Yes
Yes
No
No
Is the patient on the Liverpool Care Pathway
Yes
No
Medication Available at Home
Palliative care drug box
If Yes, Date Commenced:
/
/
Patient Insight into their condition:
Palliative Care
Preferred place of death:
Nurse Verification of Expected Death (NVED) Form Attached
Yes
No
Date NVED
Permission
/ /
Granted
Name:
Role:
NHS Email/Phone:
Is there a valid Do Not Attempt Cardio Pulmonary Resuscitation(DNACPR) Document in place for this patient?
Tick to confirm YES and that resuscitation is NOT to take place
Yes
No
Date DNACPR
/ /
Completed:
Name of GP
NHS Email/Phone:
completing form:
GP OOH USE
DNACPR form completed and made available in patient notes
ONLY
Please fax
Care Coordination Centre - Primecare 0121 2362550 (if any difficulty, call Primecare on 0330 123 1014)
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DECLARATION
Northamptonshire GP Out Of Hours
NHS 111
ICT
Primecare
Information may be shared with NHS 111, GP Out Of Hours, Urgent Care Centres and Ambulance Services
that serve the population in/bordering London. Although such sharing may occur, please be aware that this is not
guaranteed and is subject to information sharing agreements and technical interoperability between organisations.
You should ensure that consent has been obtained from the patient (and/or parents/guardian/carer if appropriate)
for the
sharing of the information contained in this Special Patient Note. If consent has not been obtained, please explain
why
(e.g. Children’s Act; lack of capacity; patient’s best interest; to protect others):
Please ensure the patient’s GP (if not you) is aware of the generation of this SPN and provided with a copy of its
content
This Special Patient Note (SPN) will update/replace any previous information shared for this patient.
You are responsible to ensure this SPN is updated/reviewed as required and if prompted, particularly at the expiry
date.
Date Completed:
/ /
SPN Expiry Date:
/ /
Defaults may be applied if not specified
Name:
Role:
NHS Email/Phone:
Please leave a copy with the patient plus forward to relevant providers:
PLEASE NOTE: If you are on TPP SystmOne there is no need to fax the Special Patient Note form to Northamptonshire GP
Out of Hours (All Localities) and Northants Intermediate Care Team (ICT).
Northamptonshire NHS 111
By email: [email protected] from a NHS mail account
(if any difficulty, call Derbyshire Health Utd on 0300
1000 404)
Northamptonshire GP Out of Hours (All Localities)
(if any difficulty, call South East Health Ltd on 01536
488820 / 01536 488821)
Intermediate Care Team (All Localities)
By email (preferred): [email protected] from a NHS mail account
By fax (safehaven): 01604 745010
Forms received no later than 16:00 will be processed and accessible
from 18:30 the same day
By fax (safehaven): 01536 527479
(if any difficulty, call 01933 235896)
INTERNAL USE ONLY:
Processed by - Name:
Date Received:
Returned due to missing vital fields?
Role:
Yes
No
**Please use same process to communicate any expirations of Special Patient Notes (i.e.
patient deceased, no longer valid). Please ensure Special Patient Notes are reviewed at
least every 12 months.
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