Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

1

Child Healthcare Record 1) DEMOGRAPHICS Name: DOB: Child’s preferred name: NHS No: Hospital Number: Home Address: Postcode: Tel: Parent/Carer Email: Parental Responsibility: Parent/Carer: Address: Address: Postcode: Postcode: Home Tel: Home Tel: Mobile: Mobile: Primary Diagnosis: Secondary Diagnosis(including dates of surgery or procedures performed): ALLERGIES: Medication (see page ____ for daily regimen) Weight: ___________ Date weighed: _________ Immunisations (including RSV / Flu vaccine) This child does / does not have an individualised treatment plan in case of an emergency (See pages ___ if applicable)

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

2

Family / Personal Details: Mother’s Name: Address: Tel: Postcode: Father’s Name: Address: Tel: Postcode: Siblings: Child lives with: Carer’s Details Address: Tel: Postcode: Child Protection Issues: Yes / No (Refer to Section 6 – Additional Family / Social Information for details) Respite (i.e. Days/Nights/Weekends and frequency): First Language: Interpreter Required? Yes / No Name & Contact Details: Religion: Ethnic Group:

Parents / carer’s smoke? Yes / No

Other information: (i.e. type of housing)

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

3

Parent & Child’s Consent to sharing Information The aim of this document is to share information concerning………………………. and parents / carers. The information held within this document is to enhance the delivery of care provided for ……………………… and parents/carers. It is designed for when …………………… is admitted to the Children’s High Dependency Unit (HDU). It is anticipated that the information provided will be documented and provide ease of use for home/community and hospital professionals involved in ……………………’s cares. The information documented within this pack will be used by the healthcare professionals involved in delivering ………………’s cares. As parent / carer, I am aware of the sharing of information held within this document and agree to the sharing of information with the health care professionals identified.

I agree / do not agree to the sharing of information. Signed: Parent/Guardian Date: Signed: Child / Young Person Date: Signed: Named Nurse (HDU) Date: Signed: Medical Practitioner Date:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

4

2) ACUTE DETERIORATION Seizure, standard advanced paediatric life support (APLS) guidelines will be followed in all cases unless there are specific instructions from the Child’s Consultant. This should be highlighted here or an attachment added as

requested. i) Seizure Management Does ____________ have known Seizures? Yes / No Medication First line: After ____ minutes

Second line:

After ____ minutes

Third line: After ____ minutes

Should ___________ require specific additional interventions, please include specific hospital based plan (Consultant letter). Buccal Midazolam provided for Home / School: Yes / No Parents trained and competent to administer? Yes / No * Refer to Section 7 for proof of competency * Authorisation Confirmed for use at school? Yes / No (Insert document if applicable) Teacher / School Nurse trained and competent? Yes / No Additional Information:

E.g. Call 999 – Emergency Transfer to Hospital: Yes / NO Additional Emergency contact numbers:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

5

ii) Acute Deterioration Management of Infections CONFIRM ALLERGY STATUS (see section 1): Preferred Antibiotic Regime (Drug, dose, route and duration etc) Instructions for emergency care for other specific circumstances: Airway / Breathing difficulties: Metabolic Disturbances: Other:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

6

iii) Personal Wishes

Wishes during life Child / Young Person’s wishes (e.g. place of care, symptom management, people involved, activities etc) Family wishes (e.g. who you would like involved, where and when etc. Medical, spiritual or cultural beliefs, wishes etc) Other wishes (Siblings, friends, school etc)

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

7

3) FUNCTIONAL ABILITY A) Airway, Breathing & Circulation Assessment

Normal observations / vital signs for _______ (Child’s Name)

Temp Resp Rate Heart Rate Oxygen saturations BP CRT Blood glucose General colour / pallor; Cough / wheeze / recession / level of respiratory distress; Ability to maintain own temperature; Additional Information: Refer to page ____ if support mechanisms required to maintain airway and

breathing – YES / NO

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

8

Support Required to Maintain Airway & Breathing

Oxygen Requirement: ____ l/min Route: (i.e. Nasal prong / Face Mask / Tracheostomy etc.) Home Oxygen established? Yes / No HOOF Form available: (please refer to Section 2 of the Toolkit) Date home oxygen installed: _________ Consumables Required: i.e. Nasal prongs, Tracheostomy, Bi-PAP etc Include Manufacturer and order details Suction required? Yes / No Suction catheter i.e. type, size and length Portable suction for child at home / school? Yes / No Nebulisers required & frequency: (e.g. saline, Salbutamol, Colomycin etc) Chest Physiotherapy – Yes / No Frequency Parents competent – Yes / No * Refer to Section 7 for proof of competency* Positioning required to maintain effective airway and breathing: Parents / Carers Basic Life Support (BLS) trained? Yes / No * Refer to Section 7 for proof of competency*

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

9

B) Neurology Child’s Neurological function / cognition / awareness: Developmental Age: Challenging behaviour: Coping mechanisms for such behaviour: Stress Management strategies: Child Parent Child’s Posture: Motor function and balance: Epilepsy / Seizures: Yes / No If applicable, type and frequency of seizures: Additional information (Continence etc)

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

10

Child’s specific behaviour: Before Seizure – After Seizure – Level of intervention usually required: (Medication – see individual profile for type and method of administration)

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

11

C) Mobility & Manual Handling Developmental stage: (i.e. what child is currently capable of doing – rolling, sitting / standing and level of dependence) Aids required to maintain this: E.g. Hoist / bed / chair / pushchair / wheelchair / splints used etc. Tissue viability assessed and interventions required:

- Pressure-relieving mattress / chair / positioning required etc. Physiotherapy / Occupational Therapy input:

- Frequency and times done with child’s routine Environmental Risk Factors:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

12

D) Nutrition & Feeding Dietician: Specific Dietary Requirements: Allergies / Intolerance: Level of assistance and aids required for feeding: Method of feeding: Orally Yes / No Nasogastric Tube Yes / No PEG / Button Yes / No Nasogastric Tube type: Frequency of change: Length at Nostril: cm Normal pH for Child: PEG / Button details: Date inserted: Second tube available – Yes / No Additional Information:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

13

Milk / Feed used: Additives / Special Instructions: Feeding regimen: Bolus – Yes / No Continuous – Yes / No

Parents / Carers trained to administer milk / feed via NG or PEG / Button –

Yes / No

• Refer to Section 7 for proof of competencies*

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

14

E) Pain, Comfort & Sleep Child’s Physical / Verbal indicators of pain: (Pain scoring tool utilised for child) Effective Pain Relief: Additional Measures: (i.e. Positioning, massage and music therapy etc) Regular sleep pattern and rest times: Additional Information (i.e. Favourite toy, comforter, story or music etc) Positioning and Safety: (Interventions . equipment used, i.e. cot sides and bumpers etc) Infection Control Risks: (Intravenous lines, feeding tubes and level of immunity etc)

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

15

F) Communication, Play and Social Development Vision / Visual aids: Hearing / Auditory aids: Touch / Sensitivity: Mode of Communication: (i.e. Speech, Makaton, Sign etc) Communication aids: Child’s common expressions / Behaviour / Personality: Learning, Social Interaction and Activities:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

16

G) Personal Care and Continence Dependent on Parents/Carers – Yes / No Assistance required maintaining personal hygiene (i.e. who does this and when does it fit with child’s daily routine?) Bladder (i.e. frequency, aids used – nappies / continence pads / urinary catheter etc) Bowels (i.e. frequency and methods used if constipated or loose stools and aids used – nappies / continence pads / toileting aid) Menstruation: Skin integrity and barrier creams if required? i.e. clean with Dermol only and napkin rash (if appropriate)

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

17

4) MEDICATION PROFILE Drug Allergies / Contraindications: Medication Name: Dose: Frequency: Times usually administered: Route of administration: Medication Name: Dose: Frequency: Times usually administered: Route of administration: Medication Name: Dose: Frequency: Times usually administered: Route of administration:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

18

Medication Name: Dose: Frequency: Times usually administered: Route of administration: Medication Name: Dose: Frequency: Times usually administered: Route of administration: Medication Name: Dose: Frequency: Times usually administered: Route of administration: Medication Routine / Aids:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

19

5) DISCHARGE PLANNING Anticipated Date of Discharge: Initial Discharge Planning meeting scheduled for: Date: Time: Venue: Lead discharge co-ordinator: Hospital Consultant: Named Nurse: Parents / Carers informed & invited to meeting? Yes / No Please see Professionals Contacts (Section 8) for contact details Health Care / Community Professional:

Invited to MDT:

Attendance present:

Informed Date of Discharge Home

Hospital Paediatrician Community Paediatrician Specialist Nurse Community Nurse Named Nurse (Hospital) Health Visitor Social Worker Key Worker General Practitioner Community & Hospital Physiotherapist

Occupational Therapist Hospital Dietician Community Dietician Speech & Language Therapist

Sensory Support Nursery / Early Years Team

Local Sure Start School School Nurse Local Respite representative

Interpreter

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

20

Support Package Required? Yes / No (Based on individual patient need) Funding application submitted? Yes / No Date: Multi-agency involvement:

• Housing • Housing suitability assessment required? Yes / No • Occupational Therapy Visit? Yes / No

Equipment: * Equipment ordered? Yes / No * Competency completed? Yes / No Batch / Inventory Number (if applicable): Servicing and Maintenance:

• Equipment Provider • Contact Number

Rehabilitation * Community Physiotherapy / Occupational Therapy aware of anticipated discharge? Yes / No Date of Home Assessment: ________ Equipment ordered or provided? Yes / No Respite Services * Aware of discharge? Yes / No * Previous visits? Yes / No * If no, have parents/carers met with staff? Yes / No - Informal visit scheduled for Date: Time: Home Oxygen Funding arranged (if applicable)? Yes / No Documentation completed? Yes / No (Refer to Section 3a if applicable) Consumables ordered? Yes / No Training All necessary Competencies completed and signed? Yes / No * Refer to Section 7 for proof of competencies *

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

21

Hospital and Community Teams aware of discharge? Yes / No Consumables / Supplies * Feed consumables ordered as per list? Yes / No Date: Signed: * Milk / feed ordered via Homeward? Yes / No Date: Signed: * Medication / TTO’s ordered? Yes / No Date: Signed: Date received on ward: * Community Pharmacist aware or regular medication? Yes / No (i.e. specific orders of meds) Feeding Regime: (if different from admission) Feeding Route: (if different from admission) Parents/Carers trained and competent? (if applicable) Yes / No *Refer to Section 7 for proof of competency* Feed/Milk; Supplier: Contact details: Specifics if applicable to child’s needs Yes / No Initial

Syringes – Type/size/connection etc Giving sets – Bolus / Continuous Pump provided pH Strips Duoderm / Tegaderm Spares Feed additives: Prescription required? Yes / No

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

22

Any other needs / areas identified during discharge planning meeting:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

23

6) ADDITIONAL FAMILY / SOCIAL INFORMATION Child Registered Disabled? Yes / No Child Registered Blind? Yes / No Child Protection Issues? Yes / No (Expand further details if applicable) Child / Family known to Social Services? Yes / No Subject to Child Protection Plan Yes / No CAF Completed Yes / No Additional Information: Parents/Carers Employment (+/- Contact details) Finances – Additional Information: DLA Yes / No

- Low / Medium / High Mobility allowance Yes / No Blue Badge Holder Yes / No Carers Allowance Yes / No Working Tax Credit Yes / No Other Volunteer / Support Groups involved:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

24

7) TRAINING & COMPETENCY Those named below are receiving / have received training in the following: (Delete as appropriate)

A) Basic Life Support (including Child specific airway and breathing management) B) Home oxygen and suction C) Home Nebulisers D) Chest Physiotherapy E) Bolus / Continuous Nasogastric / Gastrostomy feeds F) Passing a Nasogastric Tube G) Changing Button (Gastrostomy) H) Administering medication (via NG / Gastrostomy) I) Administering Buccal Midazolam

All competencies are subject to local policies, procedure and guidelines. Name: Relationship to Child / Young Person: Competencies achieved: Signature: Name: Relationship to Child / Young Person: Competencies achieved: Signature: Name: Relationship to Child / Young Person: Competencies achieved: Signature: Name: Relationship to Child / Young Person: Competencies achieved: Signature:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

25

A)Basic Life Support (including Child specific airway and breathing management) Yes / No Training package completed / DVD Yes / No Date achieved: BLS Instructor: _________________ Signed: _______________ Date: Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date: B) Oxygen and Suction Health Care / Community Professional: ____________ Signed: _______________ Date: Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date: C) Home Nebulisers Health Care / Community Professional: ______________ Signed: _______________ Date: Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date:

D) Chest Physiotherapy Hospital / Community Physiotherapist: _____________ Signed: _______________ Date: Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

26

E) Bolus / Continuous Nasogastric / Gastrostomy feeds (Delete as appropriate) Training Package completed Yes / No (including pump training, insertion of feeding tube if applicable) Health care Professional: _______________ Signed: _______________ Date: Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date: F) Passing Nasogastric Tube (if applicable) Parents / Carers have been assessed and are competent in passing ____________’s NGT in hospital / home under the supervision of trained staff Yes / No Healthcare Professional: _______________ Signed: _______________ Date: Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date: G) Changing Button (Gastrostomy) Parents / Carers have been assessed and are competent in changing __________’s button in hospital / home under the supervision of trained staff Yes / No Healthcare Professional: _______________ Date: Signed: _______________ Date: Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

27

H) Administering medication Parents / Carers have measured, prepared and administered medication (oral/ Nasogastric/Gastrostomy/and other routes) in hospital under supervision of trained staff Yes / No Healthcare professional: _____________ Signed: _______________ Date: Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date: I) Administering Buccal Midazolam Training package completed / DVD Yes / No Healthcare professional: _______________ Date: Signed: _______________ Parent / Carers signature: _______________ Date: Parent / Carers signature: _______________ Date: Competency / Training Review update: Any other details specific to Child’s needs:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

28

8) PROFESSIONAL CONTACT DETAILS Name Address / E-mail Tel

(Office/Mobile) Hospital Paediatrician

Community Paediatrician

Specialist Nurse

Community Nurse

Named Nurse (Hospital)

Key Worker

Social Worker (Area Team)

Health Visitor

General Practitioner

Hospital Physiotherapist

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

29

Community Physiotherapist

Occupational Therapist

Hospital Dietician

Community Dietician

Homeward

Speech & Language Therapist

Sensory Support / Inclusion

Nursery / Early Years team

Local Sure Start

School

School Nurse

Local Respite

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

30

Named Nurse Hospital Pharmacist

Community Pharmacist (Opening hours)

Supplies Provider Ref No:

Equipment Loan Company Ref No:

Interpreter Out-of-hours

Hospital Chaplaincy Team

Local Place of Worship

Local Council Offices

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

31

Genetics Counsellor

Child Psychologist / Family Counsellor

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

32

9) CHANGES TO INDIVIDIUAL CARE PLAN PRIOR TO DISCHARGE (FUNCTIONAL ABILITY & MEDICATION) A) Airway, Breathing & Circulation Yes / No Details: B) Neurology Yes / No Details: C) Mobility & Manual Handling Yes / No Details: D) Nutrition & Feeding Yes / No Details: E) Pain, Comfort & Sleep Yes / No Details: F) Communication, Play & Social Development Yes / No Details: G) Personal Care & Continence Yes / No Details:

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

33

Specific Amendments to Medication Regime (Any changes to administration of medicines to be included, i.e. new medication, increase in dose and/or frequency etc. Date and initial amendments.) Parents / Practitioners aware and agree with changes identified for Functional Ability? Yes / No Date for day home leave planned:

Achieved: Yes / No / NA Date for overnight home leave planned:

Achieved: Yes / No / NA

All relevant Health Care / Community Professionals aware of discharge? Yes / No

* Refer to checklist on page ___ to confirm*

Child’s Name: DOB: NHS Number: Hospital Number:

Signed: Designation: Print: Date:

34

10) ADDITIONAL INFORMATION For End-of-life documentation, please refer to Advanced End of Life Care Pathway.

West Midlands Paediatric Palliative Care Network

Children’s Healthcare Record: Special Needs Information Passport (SNIP)

Guide to Completion of the Document Authors

• Dr Nigel Coad – Consultant Paediatrician, University Hospitals Coventry & Warwickshire NHS Trust nigel.coad@uhcw.nhs.uk

• Dr Penny Dison – Consultant Paediatrician, Royal Wolverhampton Hospitals NHS Trust pennydison@nhs.net

• Sr Emma Boyle – Project Nurse Lead, University Hospitals Coventry & Warwickshire NHS Trust emma.boyle@uhcw.nhs.uk

• Sr Abbie Wood – Project Nurse Lead, Royal Wolverhampton

Hospitals NHS Trust abbiewood@nhs.net

With thanks to: - West Midlands Paediatric Palliative Care Network (WMPPCN) - South Central Child & Young Person’s Working Group for the Advance Care Plan chaired by Serena Cotterill - Coventry Community Children’s Nursing Service for sharing their work with us. - A Guide to Effective Care Planning, Assessment of Children with Life Limiting Conditions and their families, Association for Children’s Palliative Care (ACT) - Advanced End of Life Care Pathway, Fiona Reynolds, PICU Consultant, Birmingham Childrens Hospital

Introduction Within the West Midlands Paediatric Palliative Care Network (WMPCCN), a need has been identified to develop a hand-held patient passport / document to facilitate the seamless admission and discharge of children with life limiting conditions to and from hospital, specifically high dependency units (HDU). This coincides with the Department of Health (DH) Funding for Palliative Care. This document is a collaborative project between UHCW NHS Trust and the Royal Wolverhampton Hospitals NHS Trust. It is designed to be patient specific and adaptable in order to aid communication between hospital and community settings, to prevent the duplication of information and provide all necessary patient details and care plans within one concise document. Not all sections are applicable to all children, therefore please read the document thoroughly and complete applicable sections only. It is anticipated that the document will be completed on the child’s initial admission and planned discharge from HDU. It must be updated on a six month – year basis or sooner if the child has had a significant episodes requiring admission to hospital. The document is to be shared with families and all health care professionals involved in the delivery of the child and young person’s care. It is anticipated that the document is completed by the parent/carers and relevant health care professionals. The following is a guide to completing the document. We hope that it reads easily and is user friendly. Section 1

• Demographics • Family / Personal Details • Parent & Child’s Consent to sharing information This section provides confirmation of parental / child consent to allow the dissemination and sharing of all pertinent patient information detailed within the document with the relevant professionals involved in the care of their child. Allergies must be identified and clearly documented on this front page. It should be signed and dated by the parent/carers (those with parental responsibility), the child (if appropriate) and the child’s named nurse / lead practitioner. There is also a section to confirm that the information is accurate and up-to-date. This also requires the above defined signatures.

Section 2

• Acute Deterioration This section should clearly define a specific plan for parents/carers to follow in the case of sudden/acute deterioration requiring immediate medical intervention. This plan needs to be patient specific and have a clear time frame and instructions. • Seizures. Standard advanced paediatric life support (APLS) guidelines will be followed in all cases unless there are specific instructions from the child’s consultant. These should be highlighted here or an attachment added as requested. • Infection Specific antibiotic treatment should only documented here in cases where there is a specific antibiotic regime appropriate for the patient (i.e. Cystic Fibrosis). Otherwise, antibiotic treatment should be decided by the on-call Consultant. • Personal Wishes This section provides the child and family/carers space to document their personal wishes and beliefs surrounding treatment. This section is specifically designed to help improve the child and families experience and direct clinicians to providing holistic, patient centred care. • End of life plan If appropriate

Section 3

• Functional Ability - Based on the ACT pathway which includes; A) Airway, Breathing & Circulation Assessment (and Support Required

to Maintain Airway & Breathing) B) Neurology C) Mobility & Manual Handling D) Nutrition & Feeding E) Pain, Comfort & Sleep F) Communication, Play & Social Development G) Personal Care & Continence

Section 4 • Medication Profile All current medication should be clearly documented, including trade name, dose, frequency, type and route of administration. This can also be personalised to enable practitioners to be aware of the child’s specific routine so that they feel in control of some aspects of care whilst in the hospital setting.

Section 5

• Discharge Planning This section provides a comprehensive guide and checklist. It prompts the user to facilitate seamless and time efficient, sustained discharge from hospital to community care. As this is a shared document, it is to be used by parent/carers and healthcare professionals accordingly.

Section 6 • Additional Family / Social Information This section provides supplementary information regarding the family which may be pertinent in terms of planning and evaluating patient specific packages.

Section 7 • Training & Competency This section provides clear information on the training and competency of non-medical carers and family members who will be involved in the child’s on-going delivery of cares at home. All relevant carers should be documented together with details of their relationship with the child/family and authorised signatures. Relevant competencies should be highlighted, dated and signed by those practitioners, who have deemed them to be competent. These sections should be viewed early within the discharge planning stage in order to provide adequate time and training for one or more individuals. Local policies, procedures and guidelines must be adhered to, and further proof of competencies can be obtained from the hospital / community accordingly.

Section 8 • Professional Contact Details This section should be updated on a regular basis to ensure that all relevant professionals involved in the child’s care are documented with current contact information.

Section 9

• Changes to individual care plan prior to discharge This should be updated on a six month – yearly basis, or earlier if child has had a significant admission to hospital where amendments to the tool are required. This must be timed, dated and signed by the child’s HDU nurse prior to discharge home so that Parents/carers and Healthcare Professionals can review accordingly.

Section 10

• Additional Information This section is for any other documents deemed relevant to the child’s delivery of cares.

West Midlands Paediatric Palliative Care Network (WMPCCN)

Children’s Healthcare Record: Special Needs Information Passport (SNIP)

Contents Page

Page 1) Demographics & Consent * Demographics * Family / Personal Details * Parent & Child’s consent to sharing information

2) Acute Deterioration i) Seizure management and patient specific profile – Seizures ii) Management of Infections iii) Personal Wishes

3) Functional Ability A) Airway, Breathing & Circulation; Support required to maintain B) Neurology C) Mobility & Manual Handling D) Nutrition & Feeding E) Pain, Comfort & Sleep F) Communication, Play & Social Development G) Personal Care & Continence

4) Medication Profile

5) Discharge Planning * MDT Discharge planning * Discharge checklist

6) Additional Family / Social Information

7) Training & Competency

8) Professional Contact Details

9) Changes to individual care plan prior to discharge * Functional Ability & Medication

10) Additional Information