The team designed a tick-box form to assess 5 sets of case notes. The table below shows the layout they used. Each of the 5 patients has a column. Tick the box in the column for each patient if you find documented evidence that the aspect of care mentioned beside the box has been completed. A higher score = good documentary evidence this aspect has been evidence has been addressed.
| 1 | 2 | 3 | 4 | 5 | comments | |
| Discussion of DNACPR status | ||||||
| Appropriate referral to specialist palliative care service | ||||||
| Advance care directive been considered | ||||||
| Record of preferred place of death | ||||||
| Indicators of poor prognosis assessed | ||||||
| Evidence of discussion with family | ||||||
| Explore organ & tissue donation wishes of patient | ||||||
| Use of symptom assessment tool (pain, agitation, respiratory tract secretions, nausea and vomiting, dyspnoea) | ||||||
| Regular assessment of symptoms | ||||||
| Anticipatory prescribing | ||||||
| Needs of carers assessed | ||||||
| Clear plan of care | ||||||
| Outcomes of MDT meetings | ||||||
| Addressing spiritual needs |
You could also use an end-of-life quality assessment tool such as: NICE Quality standards – end-of-life quality assessment tool.
Page last reviewed: 08 Nov 2021
