PATIENT INFORMATION
Name	Click or tap here to enter text.	Date of birth	Click or tap here to enter text.
CHI number	Click or tap here to enter text.	Address	Click or tap here to enter text.
Ethnicity	Choose an item.	Post Code	Click or tap here to enter text.
Family type	Choose an item.	Religion	Choose an item.
Parent/carer Names	Click or tap here to enter text.	Sibling Names	Click or tap here to enter text.

LEAD CLINICIAN & CARE SETTING
Lead Clinician	Click or tap here to enter text.	Health Board	Choose an item.
Presenting Clinician	Click or tap here to enter text.	Current Place of Care	Choose an item.

DIAGNOSIS
Diagnosis	Click or tap here to enter text.
Diagnosis Group	Choose an item.	Current or working weight	Click or tap here to enter text.
Current medications	Click or tap here to enter text.
Allergies:	Click or tap here to enter text.

REFERRAL INFORMATION
Phase of Illness	Choose an item.	Reason for referral to the MDT:	Choose an item.
Other	Click or tap here to enter text.
Has the child already been referred to CHAS?	Choose an item.
Is consent in place for discussion at the Clinical Advisory Service & referral to CHAS?	Choose an item.

KEY QUESTIONS AND POINTS FOR DISCUSSION
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Form completed by:	Click or tap here to enter text.	Presenting Clinician:	Click or tap here to enter text.

CLINICAL SUMMARY
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SOCIAL SUMMARY
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CLINICAL COMPLEXITY INDICATORS
Airway	Choose an item.	Respiratory support – at referral	Choose an item.
Feeding Device	Choose an item.	Respiratory support – baseline at home	Choose an item.
Cardiovascular support	Choose an item.	Vascular Access	Choose an item.
Mobility aid	Choose an item.	Neurological	Choose an item.

FUTURE CARE PLANNING
Resus Status	Choose an item.	Last Updated	Click or tap to enter a date.
ACP	Choose an item.	Last Updated	Click or tap to enter a date.
SMP	Choose an item.	Last Updated	Click or tap to enter a date.
Treatment Escalation Plan	Choose an item.	Last Updated	Click or tap to enter a date.
Police Scotland Occurrence Marker/Scottish Ambulance Service alert	Choose an item.
PLEASE SEND COPIES OF ALL AVAILABLE DOCUMENTS FOR DISCUSSION AT THE MDT
Just in case medications:	Are all SMP medications PO/SC available in the home?	Choose an item.
If no which medications PO/SC are currently not available in the home?	Click or tap here to enter text.
Preferred Place of Death (PPOD) discussion offered	Choose an item.	PPOD discussion undertaken by	Click or tap here to enter text.
Agreed preference	Click or tap here to enter text.

LOCAL SERVICE PROVISION
Local medical/nursing provision (in hours)	Click or tap here to enter text.	Local medical/nursing provision (out of hours)	Click or tap here to enter text.

THE FOLLOWING SECTIONS WILL BE COMPLETED BY THE CAS TEAM DURING THE MDT.

CLINICAL ADVISORY SERVICE MULTI-DISCIPLINARY TEAM MEETING DISCUSSION & FOLLOW-UP
Date of MDT	Click or tap to enter a date.	Previously presented to MDT	Choose an item.
MDT Decision	Choose an item.	Bring Back to next CAS MDT	Choose an item.
Nursing reactive service requested	Choose an item.	Nursing reactive service provided by	Click or tap here to enter text.
Urgency of Referral	Choose an item.

CHAS services required (including for which family members)
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ACTIONS AND RECOMMENDATIONS
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MDT Chair	Choose an Item
CAS Clinicians present at MDT (Initials)	Click or tap here to enter text.
IF REFERRING TEAM HAS ANY QUESTIONS OR QUERIES, THEY SHOULD CONTACT THE SPECIALIST PALLIATIVE CARE TEAM WHICH THE CHILD IS KNOWN TO OR THE CLINICAL ADVISORY SERVICE CONTACT TELEPHONE NUMBER.