Why Amira is on the list
- Record review
- Review recommended
- Unplanned hospital episodes
- 5 in the past year
- Most recent 26 Sept 2026
- Conditions recorded
- CKD, Heart failure
- Care planning
- No advance care plan
- Not on the palliative care register in this record source
2 indicators present in the record
5 emergency admissions in 12 months (most recent 26 Sept 2026)
Shaped after SPICT general indicator GEN_ADMISSIONS
Recorded 26 Sept 2026Heart failure on the problem list, marked resolved on 13 Aug 2026. Check the record. NYHA class is not recorded in this record source.
Shaped after SPICT heart and vascular indicator, adapted: NYHA class is not present in this record source REC_HEART
Recorded 13 Aug 2026
Screening
No screening has been run for this patient.
Record review
The record supports a prompt clinical review for a goals-of-care conversation.
Prompt human review for a priorities-led goals-of-care conversation is supported by progressive heart-failure symptoms, an acute admission requiring intravenous diuresis, CKD-related monitoring needs, and unresolved home-support and care-ownership gaps. This should not be framed as a outlook-based declaration: congestion improved with treatment, and the record does not document a formal advance-care plan or the patient's broader treatment preferences.
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What the record shows
Progressive symptomatic and functional deterioration
Breathlessness progressed from tiredness walking to the shops to limitation reaching the front door, three-pillow orthopnoea, and a three-kilogram gain over two weeks, supporting a timely review of priorities alongside active treatment.
2 sources in the record
- Eligible31 Aug 2026
GP encounter records breathlessness limiting the walk to the front door, three-pillow orthopnoea, and three-kilogram weight gain over two weeks.
- Eligible19 Sept 2026
Hospital attendance records breathlessness at rest, orthopnoea, and increasing leg swelling.
Acute-on-chronic heart failure episode with renal monitoring complexity
Admission, pulmonary congestion, adjusted loop diuretic treatment, and required renal and potassium rechecking indicate clinical complexity and a need to align treatment and escalation planning with the patient's priorities.
2 sources in the record
- Eligible26 Sept 2026
Discharge summary records acute-on-chronic heart failure, pulmonary congestion, intravenous diuresis, creatinine above baseline, potassium repeat testing, and adjusted loop diuretic treatment.
- Eligible21 Jul 2026
Renal profile during fluid gain records potassium 5.5 mmol/L, creatinine 133 micromol/L, and eGFR 46 mL/min/1.73m².
Documented home priority with incomplete support and unclear ownership
A conversation can clarify what staying at home means, what support is feasible, and who the patient should contact, without assuming preferences beyond those documented.
3 sources in the record
- Eligible8 Sept 2026
Personal-context observation records: 'Stay at home with a clear contact for help'; the patient lives alone and her daughter visits after work.
- Eligible3 Sept 2026
Consultation states the daughter cannot attend during working hours and home-support arrangements remain to be confirmed.
- Eligible21 Jun 2026
Follow-up consultation records that the patient could not tell which team would arrange the next review.
What they and their family want
- The daughter asked for appointments to be grouped on one day.
- Telephone is recorded as the contact preference.
- The appointment exchange indicates an afternoon time worked for the patient.
- The patient's preferences about hospital readmission, resuscitation, ceilings of treatment, surrogate decision-making, and palliative-care involvement are not documented.
- The daughter's willingness and capacity for involvement beyond collecting a prescription, after-work visits, and weight recording are unknown.
- Decision-making capacity, accessibility needs, and consent to family participation are not documented.
4 sources in the record
- Eligible8 Sept 2026
Personal-context observation records the goal to stay at home, living alone, and daughter visits after work.
- Eligible3 Sept 2026
Consultation records a wish to return home and limits on the daughter's daytime availability.
- Eligible19 Jun 2026
Administrative observation records telephone as the contact preference.
- Eligible11 Sept 2026
Incoming appointment message says an afternoon appointment would work.
Care at present
Lives alone in a ground-floor flat.
Earlier she could walk to the shops with tiredness; by late August breathlessness limited walking to the front door. Independence in other activities and use of mobility aids are unknown.
- GP involvement is documented.
- Hospital cardiology follow-up and GP review were requested within one week of discharge.
- Daily weights and safety-netting were requested after discharge.
- Her daughter visits after work, can collect a prescription, and had agreed to record weights twice weekly earlier in the trajectory.
- Home-support arrangements were not confirmed.
- Medication reconciliation and the post-discharge renal-monitoring plan required confirmation.
- No broader formal or paid carer provision is documented.
3 sources in the record
- Eligible8 Sept 2026
Personal-context observation records living alone in a ground-floor flat and daughter visits after work.
- Eligible31 Aug 2026
GP encounter records breathlessness limiting walking to the front door.
- Eligible26 Sept 2026
Discharge summary requests cardiology and GP review within one week, daily weights, safety-netting, renal monitoring, and confirmation of home support.
Clinical decision support only. A named clinician decides. Generated 12 Sept 2026, committed for the demonstration; wording adjusted to Cairn's language rules where the review used terms Cairn avoids.