Deciding right Regional Forms

These forms and associated guidance are for use by professionals working with patients who are making advance care decisions. They are recognised by organisations across the region and should be used in all instances of advance care planning locally.  The North East Ambulance Service (NEAS) will only accept the Deciding right forms. This page has the most recent forms.  Older versions of the DNACPR form will no longer be acceptable after 31st December 2018.  Please use the most recent versions on this page for all new cases. Forms can be printed and completed manually or there is an electronic version that can be completed on screen.

 

North East Ambulance Service (NEAS) Special Patient Note (SPN) Form Version 2 (August 2018)

NEAS can apply a flag to the patients address to advise call handlers of any decisions identified on the SPN form.  The information on the SPN form will support the decision making by NEAS and help the clinicians to prioriitise if an ambulance is required.  If an ambulance crew attends the address, they will be notified of the SPN whilst on route to the address.

As from August 2018 please use the SPN form version 2 which must be completed electronically and sent via email to special.patient.notes@nhs.net 

If you require a word version of this form it can be downloaded from the NEAS website using this link

The form MUST have valid to and from dates as well as referrer details for NEAS to action the form and input the SPN onto the 999 and 111 system.

 

Do Not Attempt Cardio Pulmonary Resuscitation: DNACPR

This documents the decision not to offer cardiopulmonary resuscitation in the event of a cardiac or respiratory arrest.  It also documents the reason for the decision and other details and is concordant with the Mental Capacity Act.  This regional form applies across all care settings and in all ages.  Please make sure that the patient held form is printed in colour. Download the DNACPR NHS Print form v17a 2018 Download DNACPR COPY form v17a 2018   Download the DNACPR-NHS-Fillable-form-v17

Examples of completed DNACPR Forms

Regional Forms Example Heart Failure

Regional Forms Example Muscular Dystrophy

Ordering of DNACPR forms

DNACPR ordering information August 2017

Advance Decision to Refuse Treatment (ADRT)

This documents an adult patient’s decision to refuse a specific treatment.  It complies with requirements when refusing life-sustaining treatment and applies in all settings for people aged 18 years and over. Download the ADRT PRINT form Download the ADRT ON-SCREEN fillable Download the Advance Decisions Checklist

Mental Capacity Act Assessment Forms

The MCA1 part of this form allows a capacity assessment to be documented.  If the individual does not have capacity for a specific care decision, The MCA2 part of the form follows the requirements of the Mental Capacity Act best interests process. Download the MCA 1and2 generic – a Word document you can print and complete or complete on screen. You can also use it to add your own organisational logos.

Emergency Health Care Plan (EHCP)

This documents the care needed during and after an anticipated emergency.  These decisions will have been made with the individual if they have capacity If they do not have capacity by the best interest process, the person with parental responsibility or a court order.  It does not include a CPR decision.  It applies in all settings and all ages.

Download the EHCP NHS Fillable form

Download the EHCP NHS Print form

Download the EHCP Instructional Template

Download the EHCP Advice Sheet

Download the EHCP Useful Phrases

Advance Statement Documents

Two example Advance Statement documents from localities within the region.

Download example A

Download example B