Introduction: The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process supports personalised decision-making in emergencies where patients may lack capacity. High-quality documentation is essential for patient safety and medico-legal integrity. This audit evaluates compliance and documentation quality within Birmingham Community Healthcare NHS Foundation Trust.

Methods: A cross-sectional audit was conducted on 6 March 2024 across four inpatient sites. A total of 110 patients were reviewed using a 20-point data collection tool. ReSPECT forms, electronic records, and paper notes were assessed against seven standards based on local and national guidance.

Results: ReSPECT was considered in 86% of patients, with 95% of these having a form completed; 83% were initiated within 24 hours. Overall completion of core sections was 88%, though shared understanding (58%) and clinical recommendations (73%) were less consistently documented. Mental Capacity Assessments were recorded in 64% of relevant cases. Senior clinician oversight was present in 71%, and discussions with next of kin in 46%.

Conclusion: Despite high engagement, gaps in documentation remain, particularly in shared decision-making and capacity assessment. Targeted interventions and re-audit are recommended to improve practice.

Mubeen Hasan is a final-year medical student at Aston Medical School, currently undertaking a clinical elective in Malaysia. With a strong interest in clinical governance and patient safety, they conducted this audit at the Birmingham Community Healthcare NHS Foundation Trust to evaluate the implementation of the ReSPECT process. As they prepare to begin their Foundation Year training in the UK, Mubeen Hasan is focused on improving documentation standards and facilitating shared decision-making in emergency care settings to enhance patient-centered outcomes.