Before you start
Ensure any high NEWS2, clinical deterioration, haemodynamic instability, sepsis concern, hypoxia, chest pain risk, suspected PE risk, frailty risk, delirium, capacity concern, safeguarding concern, unsafe discharge concern, missed diagnostic concern, treatment delay or SDEC-related patient safety concern is escalated through local clinical, ED, acute medicine, specialty, operational and governance pathways. Do not rely on this audit tool for urgent escalation or SDEC referral decisions.
Case reference
Local pseudonymised reference only, for example SDEC-014. Do not enter patient names, NHS numbers or hospital numbers.
Episode context
Pseudonymised episode details only — no direct patient identifiers.
SDEC suitability decision
Referral and transfer
Clinical assessment and risk
Same-day diagnostics, treatment and support
Discharge, follow-up and outcome
Safety, learning and local comments
Bespoke additional fields
Project-specific fields configured in Project setup.
Local slot categories used by this SDEC unit.
Audit criteria
Answer each criterion. Not applicable and Unable to determine are excluded from compliance calculations.
0 / 30 answered
c1SDEC suitability was considered for the patient where clinically relevant.
c2Local SDEC inclusion criteria were assessed and documented.
c3Local SDEC exclusion criteria were assessed and documented.
c4Presenting problem or pathway group was documented clearly.
c5NEWS2 or equivalent acuity assessment was documented.
c6Clinical stability and immediate safety were assessed.
c7Senior clinical decision-maker was involved where required by local policy.
c8Frailty assessment, Clinical Frailty Scale or equivalent was documented where relevant.
c94AT, cognition or delirium screening was documented where relevant.
c10Safeguarding, capacity, functional or social risk was considered where relevant.
c11SDEC referral was made where the patient appeared suitable.
c12Reason for not referring to SDEC was documented where the patient appeared potentially suitable but was not referred.
c13Referral route used was appropriate to local policy.
c14SDEC referral outcome was documented.
c15Reason for SDEC referral decline was documented where applicable.
c16Transfer from ED / UTC to SDEC occurred within local expected timeframe where applicable.
c17Required diagnostics were identified and available within the same-day pathway where relevant.
c18Diagnostics were completed same day where required for safe SDEC management.
c19Required treatment was identified and delivered same day where relevant.
c20Pharmacy, medicines or prescribing support was completed where required.
c21Specialty advice was completed same day where required for safe SDEC management.
c22Discharge plan was documented where same-day discharge was intended or achieved.
c23Safety-netting advice was documented.
c24Follow-up plan was documented where required.
c25Patient information was provided where relevant.
c26Same-day discharge was achieved where clinically appropriate.
c27Reason for admission after SDEC assessment was documented where admission occurred.
c28Alternative pathway was documented where SDEC was not used.
c29Documentation was clear enough for another clinician or coordinator to understand suitability, decision, pathway and next actions.
c30Any SDEC suitability, streaming, discharge or patient safety concern was escalated or actioned where identified.