Care team
3 in the teamWho needs to be involved, and why
Every participant carries a reason and the record entry behind it, so the list can be checked rather than trusted. Colleagues other than the signed-in clinician are simulated for this demonstration.
- Dr Maya Shah
Usual GP · Riverside Practice
Registered GP; holds the record.
EvidenceDr Maya Shah, the GP named on the appointment record
- Dr Helen Okaforsimulated
Palliative care consultant · Neighbourhood hospice
Multiple indicators present; the tier calls for a palliative care view.
EvidenceTier 'review this month': Two or more unplanned admissions in the past year; Heart failure recorded, severity grade not recorded
- Priya Ramansimulated
Heart failure specialist nurse · Northbank General
Heart failure indicator present in the record.
EvidenceHeart failure on the problem list, marked resolved on 13 Aug 2026. Check the record. NYHA class is not recorded in this record source.
Suggested by the record review
3 suggestedA read-only reading of the whole record, checked by a second pass. Each suggestion carries its reason and the record entries behind it. Nobody joins the team unless you add them.
- Duty GP or usual GP clinicianCore to the meetingalready on the team
Own the prompt record review, invite the patient using her contact preference, reconcile outstanding information, and document agreed next steps after human clinical review.
The discharge handover is assigned to the duty GP and requests GP follow-up within one week.
- Eligible26 Sept 2026
Heart-failure discharge is assigned to the duty GP and requests GP review within one week.
- Cardiology or heart-failure clinicianCore to the meeting
Clarify the current heart-failure treatment and monitoring plan, likely options, and clinical safety-netting for the GP-led priorities conversation.
The admission involved acute-on-chronic heart failure, adjusted diuretic treatment, and requested cardiology review within one week.
- Eligible26 Sept 2026
Discharge summary documents acute-on-chronic heart failure, diuretic adjustment, and cardiology review requested within one week.
- Discharge or community-care coordinatorOptional
Confirm feasible home support and provide a named route for help if the patient wants home-focused planning.
Home support remained unconfirmed and the patient wanted a clear contact for help.
- Eligible3 Sept 2026
Consultation records a wish to return home and states home-support arrangements remain to be confirmed.
- Eligible8 Sept 2026
Personal goal is to stay at home with a clear contact for help.
Add a participant
Personal details
Auto-filled from the patient record. SIM-000001
What matters to the patient
Their words come first. Set in the voice face, quoted, never paraphrased.
Capacity for this decision
requiredWhether the person had capacity for this decision when it was made.
Patient's expressed wishes
requiredIn their own words, from the conversation.
Patient's expressed fears and concerns
What they are worried about, in their words.
What is most important to the patient about how they are treated
requiredWhere their priority sits between comfort and life-sustaining treatment.
Clinical context
The picture a colleague needs before reading the recommendations.
Diagnosis summary
requiredThe relevant conditions and recent events, as recorded.
Likely clinical trajectory
How things have been changing for this person, from the record.
Relevant active medications
Medicines that matter in an emergency, as the record lists them.
Recommendations for emergency care
Recommendations, not legally binding. Clinical judgement applies. This is not a DNACPR form.
CPR recommendation
requiredA clinical recommendation agreed with the person; not legally binding and not a DNACPR form.
Rationale
Why, and who it was discussed with.
Escalation ceiling
requiredThe level of treatment the team recommends if the person becomes unwell.
Rationale
Why this ceiling, in a sentence a colleague can check.
Clinical priorities if the patient deteriorates
requiredWhat should happen first, and who should be involved.
Signatures and review
0 of 7 required fields recorded.
Still needed: Capacity for this decision, Patient's expressed wishes, What is most important to the patient about how they are treated, Diagnosis summary, CPR recommendation, Escalation ceiling, Clinical priorities if the patient deteriorates.