Care team
1 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
Suggested by the record review
2 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.
- Responsible GP or primary-care clinicianCore to the meeting
Confirm the longitudinal record, check existing planning and patient communication needs, and coordinate a priorities conversation with the current hospital team if the patient remains admitted.
GP-owned encounters contain the longitudinal symptom history and the recorded telephone contact preference.
- Eligible
GP resources document serial symptoms, weight change and telephone contact preference.
- Current renal medical team clinicianCore to the meeting
Clarify the acute diagnosis, reversibility, treatment response and current clinical status, and lead any inpatient discussion if clinically appropriate.
The latest documented event is acute medical unit arrival with the renal medical team identified as clinician.
- Eligible11 Aug 2026
The hospital attendance records the acute medical unit location and renal medical team clinician.
Add a participant
Personal details
Auto-filled from the patient record. SIM-000395
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.