Release Notes:
Data Element
Version 2022B
| Name: | Resident Preferences and Goals of Care |
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| Collected For: |
ALC-03 |
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| Definition: | There is documentation in the resident’s record that the assisted living care team discussed or attempted to discuss the resident’s preferences and goals for care. Documentation should include a discussion on preferences and goals including, but not limited to:
- Hospitalization or transfer preference
- Medication management
- Wound care
- Activity planning
- Dietary services
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| Question: | Is there documentation in the resident’s record that the assisted living care team discussed or attempted to discuss the resident’s preferences and goals for care? |
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| Format: |
| Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) There is documentation in the resident’s record that the assisted living care team discussed or attempted to discuss the resident’s preferences and goals for care.
N (No) There is no documentation in the resident’s record that the assisted living care team discussed or attempted to discuss the resident’s preferences and goals for care or unable to determine.
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| Notes for Abstraction: |
- A discussion about preferences and goals of care can be initiated by any member of the assisted living care team.
- Documentation must include the specific preferences discussed.
- Example: “discussed hospitalization and if needed Mr. Smith does not wish to be transferred to the hospital.
- Goals of care are related to quality of life and may include rehabilitation or comfort care.
- Facilities should have a conversation with the resident about their preferences and goals of care. The measure is not capturing the number of preferences/goals discussed.
- For the purpose of this resident-centered measure, the documentation should indicate that the resident, family or surrogate was involved in the discussion of preferences and goals of care and care planning (i.e. that it was not completed solely by the clinician without input by the resident).
- Preferences and goals of care should be derived based upon the residents expressed preferences, values, needs, concerns and/or desires, through clinician-led discussion, professional guidance and support for resident and family decision making.
- Family is determined by the resident. Family may be defined as a person or persons who play a significant role in an individual’s life.
- A surrogate decision-maker is someone legally appointed to make decisions on behalf of another. This individual can be a family member, or someone not related to the individual. A surrogate decision-maker makes decisions when the individual is without decision-making capacity or when the individual has given permission to the surrogate to make decisions. Such an individual is sometimes referred to as a legally responsible representative.
- If the resident or family declines to discuss the goals of care, and the documentation reflects this, select ‘Yes’.
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| Suggested Data Sources: |
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| Additional Notes: |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
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None
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None |
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