Areas of good practice
Documentation type was clear (DNACPR, ReSPECT, local TEP, advance care plan or equivalent).
100%
Any DNACPR / ReSPECT / treatment escalation safety concern was escalated or actioned where identified.
100%
Priority gaps
The plan was reviewed after significant clinical change, transfer, new senior review or change in goals of care where relevant. (target ≥ 85%)
50%
Patient involvement was documented where appropriate. (target ≥ 85%)
53.3%
Advance decision to refuse treatment or legal proxy status was considered where relevant. (target ≥ 85%)
56.7%
Out-of-hours deterioration plan was documented where clinically relevant. (target ≥ 80%)
58.3%
Discharge communication included DNACPR / ReSPECT / TEP status where relevant and locally appropriate. (target ≥ 85%)
61.7%
Best interests decision-making was documented where the patient lacked capacity and a decision was required. (target ≥ 90%)
65%
Broader treatment escalation recommendations were documented where ReSPECT or local TEP is used. (target ≥ 90%)
68.3%
Senior clinician responsibility was documented in line with local policy. (target ≥ 90%)
68.3%
Patient wishes, values, goals or priorities were documented where possible. (target ≥ 85%)
70%
Family, carer, legal proxy or important-person communication was documented where appropriate. (target ≥ 90%)
71.7%
Ceiling of care was documented where clinically relevant. (target ≥ 85%)
73.3%
The plan was visible and accessible in the clinical record. (target ≥ 95%)
75%
Documentation was clear enough for another clinician to understand CPR and treatment escalation recommendations. (target ≥ 90%)
75%
The plan was communicated to the MDT, nursing team or relevant clinicians where appropriate. (target ≥ 85%)
80%
ReSPECT, DNACPR or TEP form was complete according to local documentation requirements. (target ≥ 90%)
83.3%
The documentation was completed, reviewed or authorised by an appropriate clinician according to local policy. (target ≥ 90%)
83.7%
Patient capacity was documented where a decision or discussion was required. (target ≥ 90%)
85%
Clinical rationale for the recommendation or decision was documented. (target ≥ 90%)
86.7%
Relevant DNACPR, ReSPECT or local treatment escalation documentation was present where clinically required or considered. (target ≥ 90%)
88.3%
CPR recommendation was clearly documented where applicable. (target ≥ 90%)
88.3%
User commentary
Editable interpretation for reports and governance meetings.
Governance & safety implications
Any immediate deterioration, CPR decision concern, treatment escalation uncertainty, capacity concern, best interests issue, safeguarding concern, conflict, communication failure or unresolved DNACPR / ReSPECT / TEP concern identified during this audit must be escalated through local clinical, palliative care, resuscitation, critical care and governance pathways. This tool does not replace local escalation processes.