PEPSI COLA Communication Pro Forma - East Midlands Cancer ...

PEPSI COLA Communication Pro-FormaPatient Name:Address:GP Details:NHS No:Hospital No:Completed by (name & designation)Contact Details:PPhysicalEEmotionalPPersonalConsider Date / Signature Patientsneedsare met• Symptom Control and use of tools• Medication – Regular/PRN____/____/____ □• Compliance/stopping non essentialtreatments• Treatment/medication side effects• Alternative therapy referral• Understanding expectations of patient• Low mood, fears, anxieties, strengths ____/____/____ □• Coping mechanisms and interests• Altered body image• Relationships with others• Patient/family’s cultural background/ ethnicgroup____/____/____ □• Needs related to spiritual wellbeing, ie:support structures, space to reflect/pray/quiet time• Patient’s concerns/desires future andpresent• Worries and challenges• Religious itemsPatients needs not met(what needs doing Action Plan)Kindly reproduced and adapted from the GSF toolkit 2004 by The Mount Vernon Cancer Network

PEPSI COLA Communication Pro-FormaSSocialSupportConsider Date / Signature Patientsneedsare met• Care for carers• Practical/family support____/____/____ □• Occupational/financial welfare supportservices• Social & recreational activitiesPatients needs not met(what needs doing Action Plan)IInformationCommunication• Identify the key team as per EMCN MDTpolicy• Liaison with MDT/PHCT or the receivinghealth care worker• Appropriate patient information leaflets____/____/____□CControlOOut of Hours• Discussion around patient choice• Patient dignity• Treatment options/plans discussed• Preferred place of care documented• Advanced care planning• Communication to out of hours service(OOH)• Access to drugs/equipment• Ensure continuity of care____/____/________/____/____□□LLiving withyour illness• Follow up care• Rehabilitation support• Patient/carer expectations• End of life care planning (if appropriate)• Liverpool Care Pathway• GSF register____/____/____□AAfter Care• Future support - family/patient• Discharge planning• Reassessment• Bereavement follow up____/____/____□Kindly reproduced and adapted from the GSF toolkit 2004 by The Mount Vernon Cancer Network