Documentation and sharing

Recording the outcomes of Anticipatory Care Planning (ACP) conversations and sharing them with those that need to know helps everyone understand the priorities for treatment and care. This helps to ensure that the right decisions are made at the right time.

There are a wide range of tools that support the gathering and sharing of information from ACP conversations. Some of the most commonly used are listed below. It is important to select an appropriate tool for your service or patient and equally important that the individual should be the focus of the interaction. ACP should never be seen as a tick-box or form-filling exercise. How this is documented and shared is important but secondary to having the conversation.

Key Information Summary

The Key Information Summary (KIS) remains the best way to share ACP information electronically between health professionals within Scotland. The KIS is created within the GP clinical systems and can be accessed by professionals working within NHS24, GP out-of-hours services, Scottish Ambulance Service, Emergency Departments in acute hospitals, and other providers of unscheduled healthcare.

Advice on what constitutes a quality KIS is available in the KIS best practice statement from the Scottish Government. In the year following the COVID-19 pandemic, the number of KIS increased from 250,000 to 1.7 million. Over 30% of the Scottish population now has a KIS. Keeping these summaries up to date is a logistical challenge for primary care teams. In November 2021 we updated guidance to support GP Practices on how to review and update their KIS published in March 2021.
My ACP

My ACP is a comprehensive 38-page booklet which is designed for individuals to complete with health or social care staff. My ACP also includes supplementary resources, for example a range of leaflets.

All the My ACP resources can be found on our My ACP webpage.
The Essential ACP

The Essential ACP was created during the COVID-19 pandemic to document important information about preferences for care and those that should be involved in decisions about care in the event of a serious illness. As of July 2022 the Essential ACP Online Tool has been withdrawn. The word template and guidance resources can be found on our Essential ACP webpage.
ReSPECT

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a process that supports the creation of personalised recommendations for a person’s clinical care and treatment in case of a future emergency. It has been developed by the Resuscitation Council UK and more informational is available at the ReSPECT website. Several health boards in Scotland are piloting the use of ReSPECT, and the NHS National Education for Scotland Digital Service (NDS) is developing an electronic platform through which the information captured can be shared. Check the NDS website for updates on this work.

Get in touch

If you have tools or resources that have supported you in preparing for and undertaking ACP, or you want to provide feedback, please get in touch by emailing us at

his.pcpteam@nhs.scot