Release Notes:
Data Element
Version 2022B
| Name: | Advanced Care Plan/Surrogate Decision Maker |
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| Collected For: |
ALC-04 |
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| Definition: | Documentation of an advanced care plan or a surrogate decision maker in the resident’s record. An advance care plan includes instructions given by individuals specifying what actions should be taken for their health if they are no longer able to make decisions due to illness or incapacity, and therefore appoints a person to make such decisions on their behalf. |
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| Question: | Is there documentation of an advanced care plan/surrogate decision maker in the resident’s record? |
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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) Documentation of an advanced care plan/surrogate decision maker was present in the resident’s record or the resident refuses.
N (No) There was no documentation of an advanced care plan/surrogate decision maker in the resident’s record, or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- If the resident is given written information on resources to formulate an advanced directive, select ‘Yes’.
- If there is documentation of a discussion initiated by the assisted living community staff, but the resident declined the discussion, select ‘Yes’.
- If there is documentation that the resident has an advanced care plan, but a copy is not present in their record, select ‘No’.
- See inclusion list for acceptable documentation of and advanced care plan.
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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 |
- Advance care plan
- Advance decision
- Advance directive
- Advance healthcare directive
- Health care proxy
- Living will
- MOLST (Medical Orders for Life-Sustaining Treatment)
- Personal directive
- POLST (Physician Orders for Life-Sustaining Treatment)
- Power of attorney for healthcare
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- Do Not Resuscitate (DNR) Orders
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