Why Daniel is on the list
- Record review
- Review recommended
- Conditions recorded
- CKD, Heart failure, Arthritis
- Care planning
- No advance care plan
- Not on the palliative care register in this record source
1 indicator present in the record
Heart failure on the problem list, active, recorded 14 Feb 2026 (SIM-PROBLEM-3). 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 14 Feb 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 clinician review is supported for a sensitive priorities-and-future-care conversation. The record describes active heart failure and CKD, reduced appetite and intake, increasing weakness and nausea, and a recent assessment with pulse 104 bpm, blood pressure 96/58 mmHg, and postural light-headedness. These findings also warrant timely clinical assessment for potentially reversible causes; they do not establish outlook.
Show the full review
Later renal results were substantially better than the June abnormal profile, so the trajectory is mixed and should not be overstated. No active advance-care or palliative plan is documented in this snapshot.
What the record shows
Recent symptomatic decline and reduced intake
Less appetite, increased daytime sleep, later increasing weakness and intermittent nausea with difficulty keeping fluids down, and a final observation of reduced intake with postural light-headedness indicate a clinically important change that merits prompt holistic review.
1 source in the record
- Eligible
GP encounters document less appetite and more daytime sleep, then increasing weakness, intermittent nausea, and difficulty keeping fluids down; the latest observation records reduced intake and postural light-headedness.
Low blood pressure with tachycardia
The recorded pulse of 104 bpm and blood pressure of 96/58 mmHg alongside poor intake may reflect an acute, potentially reversible problem and requires clinical review rather than outlook-based interpretation alone.
1 source in the record
- Eligible
The latest GP observation records pulse 104 bpm, blood pressure 96/58 mmHg, reduced oral intake, and postural light-headedness.
Chronic cardiac and renal disease with prior biochemical deterioration
Active heart failure and CKD provide relevant chronic-disease context, while the June hyperkalaemia and renal impairment show prior physiological vulnerability despite subsequent improvement.
3 sources in the record
- Eligible15 May 2026
The longitudinal GP problem list records CKD as active.
- Eligible14 Feb 2026
The longitudinal GP problem list records heart failure as active.
- Eligible20 Jun 2026
The renal report records potassium 5.7 mmol/L, urea 8.6 mmol/L, creatinine 118 micromol/L, and eGFR 54.
What they and their family want
- Letter is recorded as the contact preference.
- The patient's priorities, understanding, desired level of involvement, and preferred place of care are unknown.
- Family or carer identity, availability, wishes, and permission to involve them are unknown.
- Decision-making capacity, health and welfare attorney status, ADRT, DNACPR, ReSPECT, and any advance-care plan are unknown.
- It is unknown whether letter remains suitable for urgent clinical contact; the recorded preference should be confirmed directly.
1 source in the record
- Eligible
GP observations record the administrative contact preference as letter; the snapshot does not document patient wishes, family wishes, carers, capacity, attorneys, or legal care-planning records.
Care at present
Unknown; the snapshot does not document where the patient lives or the care setting.
Baseline function and mobility are unknown; recent weakness and postural light-headedness are documented, but no activities-of-daily-living or mobility baseline is recorded.
- GP has documented the recent encounters and observations and owns an open task to confirm follow-up arrangements.
- Diagnostics produced the available blood-test reports.
- Residence, usual function, mobility, falls risk, frailty, cognition, and ability to manage food and fluids are not documented.
- No medication list is available in the EHR resource despite active CKD and heart failure.
- No named family member, carer, community service, heart-failure service, renal service, or palliative-care service is documented.
1 source in the record
- Eligible
GP owns the symptomatic encounters, latest observations, and an open follow-up task; diagnostics owns blood reports. Residence, functional baseline, carers, named specialist services, and medications are not documented.
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.