Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: Goals of Care
Collected For: PAL-04
Definition:There is documentation in medical record that the palliative care team discussed or attempted to discuss the patient’s goals for care.
Suggested Data Collection Question:Is there documentation in medical record that the palliative care team discussed or attempted to discuss the patient’s goals for care?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y    (Yes)   There is documentation in medical record that the palliative care team discussed or attempted to discuss the patient’s goals for care.

N    (No)   There is no documentation in medical record that the palliative care team discussed or attempted to discuss the patient’s goals for care or unable to determine from the medical record documentation.
Notes for Abstraction:
  • Goals of care may be curative, rehabilitative, life-prolonging, or comfort focused.
  • For the purpose of this patient-centered measure, the documentation should indicate that the patient, family or surrogate was involved in the discussion of goals of care and care planning (i.e. that it was not ordered solely by the clinician without input by the patient). Examples include (but not limited to) “discussed goals of care with patient, who chooses to…” “patient indicated desire to,” or “patient verbalized agreement with plan to” may be illustrative of collaborative goals of care discussion.
  • Goals of care should be derived based upon the patient’s expressed preferences, values, needs, concerns and/or desires, through clinician-led discussion, professional guidance and support for patient and family decision making.
  • Family is determined by the patient. Family may be defined as a person or persons who play a significant role in an individual’s life. A family is a group of two or more persons united by blood or adoptive, marital, domestic partnership, or other legal ties. The family may also be a person or persons not legally related to the individual (such as a significant other, friend, or caregiver) whom the individual personally considers to be family. A family member may be the surrogate decision-maker if authorized to make care decisions for the individual should he or she lose decision-making capacity or choose to delegate decision making to another.
  • 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 patient or family declines to discuss the goals of care, and the documentation reflects this, select “Yes.” This would include statements such as, “I don’t want to talk about this” or “I’m only going to talk to my priest about this”.
  • A discussion about goals of care can be initiated by any member of the palliative care core interdisciplinary team. The core interdisciplinary team is comprised of the following: Physician(s); Registered nurse(s) or advanced practice nurse(s); Chaplain(s) or, spiritual care professional(s); Social worker(s).
Suggested Data Sources:

  • Palliative care consultation notes
  • Palliative care team progress notes
  • Palliative care initial encounter notes
  • Palliative care admission assessment
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Goals of Care
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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