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P87 May I?: Audit of documentation of consent for care
  1. Helen Birch,
  2. Catherine Baldry,
  3. Karen Groves and
  4. Shirley Balmer
  1. Queenscourt Hospice, Southport, UK


Aims Consent to valid treatment and care is central in all forms of healthcare: patients have a fundamental, legal and ethical right to determine what happens to them. Hospice at Home works with community services to fill gaps in end of life care for patients whose preferred place of care is home. Care is provided predominantly by health care assistants, and a few registered nurses (RN’s). RN’s receive consent training in their nursing studies. The aim was that all hospice at home evaluations should clearly state ‘consent status documented for all care interventions given’. Many patients are unconscious and unresponsive when care interventions occur. Hospice policy states ‘Consent status must be documented for all personal and invasive procedures’. It was difficult to see at a glance if consent status was recorded in the care plan.

Method A retrospective (random) audit of 204 care plans was performed to determine if consent status for personal care was documented. Confidentiality was maintained at all times. 77% records completed by HCAs and 23% by RNs

Result Cycle 1 -74% of care plans had consent status recorded. 26% records had no evidence of consent status documented. Further analysis identified only 37% of RNs had recorded consent status. Training needs were identified and implemented in various ways to include Consent, Mental Capacity Act (2005), and Record keeping. Cycle 2 Re- audited 6 months later using same criteria and data collection tools. - 93% of care plans had consent status recorded for personal care, improvement in the number of RN’s recording consent status- 77% Results Care plans now checked daily to identify staff not adhering to policy. The need to replicate audit in other areas of the Palliative Care Services was highlighted. Induction and in- service training now includes education on consent and good record keeping for all grades of staff. Re-audit in 12 months to ensure improvement continues

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