DNACPR / ReSPECT Documentation Audit

This project audits whether DNACPR and ReSPECT documentation supports safe, person-centred emergency decision-making. It reviews whether the CPR recommendation and any wider emergency care recommendations are clearly recorded with clinical rationale, whether the person's priorities and discussions are documented (or a reason recorded where discussion did not occur), whether capacity, best-interests process, consultation and legal authority are addressed, and whether the plan is dated, reviewed, completed to local standard, visible, consistent across systems and communicated at handover, discharge, transfer and to out-of-hours or ambulance services.

• Doctors, nurses, ACPs, PAs and AHPs completing or reviewing DNACPR and ReSPECT documentation
• Frailty, palliative care, acute medicine, emergency department and critical care outreach teams
• GP practice, community, care-home and hospice clinical teams
• QI leads, governance and patient safety teams
• Supervisors and educators supporting ARCP and appraisal evidence

• Measure completeness and clarity of CPR and emergency care recommendations
• Assess documentation of person-centred discussion, priorities and reasons where discussion did not occur
• Review capacity, best-interests, consultation and legal authority documentation
• Test review arrangements, visibility, consistency and transfer-of-care communication
• Generate governance-ready and ARCP-ready evidence and a re-audit cycle

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised context (age band, sex/gender recorded, care setting, DNACPR / ReSPECT context)
• Clinical area / location and optional specialty / service
• Twenty-four DNACPR / ReSPECT documentation criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• Resuscitation Council UK, BMA and RCN

  Decisions relating to cardiopulmonary resuscitation (3rd edition)(opens the original source in a new tab)

  Joint national guidance on making, recording, reviewing and communicating CPR decisions.

• Resuscitation Council UK

  ReSPECT process and resources(opens the original source in a new tab)

  The Recommended Summary Plan for Emergency Care and Treatment: person-centred recommendations for emergency care, used where locally adopted.

• GMC

  Treatment and care towards the end of life: good practice in decision making(opens the original source in a new tab)

  Professional standards for end-of-life decision making, including CPR decisions, discussion and record keeping.

• NICE

  NG108: Decision-making and mental capacity(opens the original source in a new tab)

  Expectations for supporting decision-making, assessing capacity and documenting best-interests decisions.

• NICE

  NG142: End of life care for adults — service delivery(opens the original source in a new tab)

  Service expectations for advance care planning, review and communication across settings, where locally relevant.

• NICE

  NG197: Shared decision making(opens the original source in a new tab)

  Supports documentation of the person's priorities, values and preferences in emergency care planning.

• CQC

  Regulation 11: Need for consent(opens the original source in a new tab)

  Regulatory expectations for consent, capacity and best-interests processes where relevant to CPR and escalation decisions.

• Local policy

  Local DNACPR, ReSPECT, escalation, capacity and transfer policies

  Local DNACPR policy, ReSPECT policy, treatment escalation plan and emergency care and treatment plan policy, advance care planning policy, Mental Capacity Act and best-interests policy, consent policy, palliative care and frailty pathways, discharge and transfer-of-care standard, ambulance and out-of-hours communication policy, EPR form completion guidance and incident reporting policy define what is required locally. Form rules, review intervals, seniority and signing requirements, visibility rules and escalation categories are set locally. Confirm local policy before setting targets.

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports documentation review only. It does not provide patient-specific CPR decisions, legal advice, capacity or best-interests decisions, emergency treatment recommendations or end-of-life treatment advice.
• Form rules, review intervals, seniority and signing requirements, visibility rules, escalation categories and transfer routes are locally configured and are not presented here as national standards.
• Use anonymous case identifiers only — never patient-identifiable information, and never identifiable detail about family members, attorneys, deputies, carers or staff.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Quality ImprovementPlanning Effective PDSA Cycles for Quality ImprovementThis guide provides a practical, step-by-step approach to planning effective Plan-Do-Study-Act (PDSA) cycles for quality improvement initiatives within the NHS, focusing on robust design and learning. It covers essential considerations from defining your aim to anticipating challenges, helping teams systematically test changes.
• Clinical GovernanceIntegrating Quality Improvement into Clinical Governance FrameworksThis article explores the vital relationship between Quality Improvement (QI) and Clinical Governance within the NHS, demonstrating how they are two sides of the same coin when aiming for continuous, systematic improvement in patient care.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.