2010-08-19 Electronic Form Instructions v2

Instruction for use of Electronic Unified Do Not Attempt
Cardiopulmonary Resuscitation (uDNACPR) form
1. Completed form
Print the form on Lilac paper (only page 2 is required when printing), ensure it is signed –
this is the person’s copy.
Policy 8.8
The form will stay with the person; it will be located in the following places:
Hospitals, nursing homes, in-patient specialist palliative care setting: in the front of person’s
notes.
In the home: The tear off slip should be completed and placed in the “message In a bottle” in
the person’s refrigerator. The location of the DNACPR form needs to be clearly stated on the
tear off strip. If a “message in a bottle” is not available, a system needs to be put in place to
ensure effective communication of the DNACPR form’s location to all relevant parties
including South Central Ambulance Service.
www.lionsmd105.org/Community/MIAB/where_botlle.htm
2. Audit Copy
Hospitals and Specialist Palliative Care areas
i. Print and sign as above and place lilac form in the person’s notes. When the
person is discharged ensure this completed form is copied and stored for audit
purposes.
Person’s Home and Nursing / Care homes
ii. Print and sign as above and place lilac form in the person’s notes. Print a
second white copy, sign it and retain for audit purposes.
Policy 8.6.2
……. A second copy needs to be stored for audit purposes.
3. Copying the DNACPR Form
If the form is copied (on white paper only) or you receive a copy (a fax / email generates
a copy) the form should be crossed through with 2 diagonal lines in black ball-point ink
and the word ‘COPY’ written clearly between them.
4. Ordering details for Lilac Paper
Paper specification - Description Paper Copier A4 80gsm. Colour Lilac. Company
Premier Paper Group
Order via e-procurement - Product Code WHO391
Or via paper company, Premier Paper Group, Head Office, Midpoint Park, Kingsbury
Road, Min Worth, Birmingham B76 1AF. Tel: 0121 313 1115. www.paper.co.uk
uDNACPR Electronic form instructions v2
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