Aims: To examine user compliance and completeness of documentation with a newly designed observation and response chart and whether a rapid response system call was triggered when clinically indicated. Background: Timely recognition and responses to patient deterioration in hospital general wards remain a challenge for healthcare systems globally. Evaluating practice initiatives to improve recognition and response are required. Design: Two-phase audit. Methods: Following introduction of the charts in ten health service sites in Australia, an audit of chart completion was conducted during a short trial for initial usability (Phase 1; 2011). After chart adoption as routine use in practice, retrospective and prospective chart audits were conducted (Phase 2; 2012). Findings: Overall, 818 and 1,058 charts were audited during the two phases respectively. Compliance was mixed but improved with the new chart (4%–14%). Contrary to chart guidelines, numbers rather than dots were written in the graphing section in 60% of cases. Rates of recognition of abnormal vital signs improved slightly with new charts in use, particularly for higher levels of surveillance and clinical review. Based on local calling criteria, an emergency call was initiated in 33% of cases during the retrospective audit and in 41% of cases with the new chart. Conclusions: User compliance was less than optimal, limiting full function of the chart sections and compliance with local calling criteria. Overcoming apparent behavioural and work culture barriers may improve chart completion, aiding identification of abnormal vital signs and triggering a rapid response system activation when clinical deterioration is detected.