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.
EvidenceRegistered GP on the patient 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 found in a discharge summary on 26 Aug 2026: "Acute breathlessness and increasing peripheral oedema in established heart failure.". 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.
- Primary care clinicianCore to the meeting
Confirm current status, reconcile the follow-up plan, ask the patient whom they want involved, and own invitation and documentation of a priorities conversation.
The discharge summary assigns repeat U&E, diuretic-response review, and blood-pressure review to the practice, and GP is a longitudinal record owner.
- Eligible26 Aug 2026
Discharge summary assigns repeat U&E, diuretic-response review, and blood-pressure review to GP practice.
- Heart-failure clinicianCore to the meeting
Explain the heart-failure course, treatment options and uncertainties, and agree escalation and symptom-management recommendations with the patient and primary care.
The patient had a recent acute decompensation and a heart-failure review was requested within one week.
- Eligible26 Aug 2026
Discharge summary documents acute decompensated heart failure and requests heart-failure clinic review within one week.
- Renal clinicianOptional
Advise on renal and potassium constraints if these remain clinically active, preferably by written input unless attendance is needed.
Cardiorenal vulnerability and potassium surveillance were documented, and renal review was requested.
- Eligible26 Aug 2026
Renal function remained below baseline, potassium surveillance was required, and renal clinic follow-up was requested.
Add a participant
Personal details
Auto-filled from the patient record. SIM-000261
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.