Release Notes:
Data Element
Version 2018B1
| Name: | Advance Directive Executed |
|---|
| Collected For: |
ACHF-05, ACHFOP-07 |
|---|
| Definition: | Documentation in the medical record that the patient has an advance directive. An advance directive is instructions given by individuals specifying what actions should be taken for their health in the event that 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. |
|---|
| Question: | Was documentation present in the medical record that the patient has an advance directive? |
|---|
| Format: |
| Length: | 1 |
|---|
| Type: | Alphanumeric |
|---|
| Occurs: | 1 |
|---|
|
|---|
| Allowable Values: |
Y (Yes) There was documentation present in the medical record of an advance directive.
N (No) There was no documentation present in the medical record of an advance directive, or unable to determine from medical record documentation.
|
|---|
| Notes for Abstraction: |
- If there is documentation of an advance directive present in the medical record, select “Yes”.
- If the only documentation in the medical record is that the patient was asked if they have an advance directive and the patient response is no, select No.
- If there is documentation that the patient has an advance directive but a copy is not present in the medical record, select Yes.
- See inclusion list for acceptable documentation of advance directive.
|
|---|
| Suggested Data Sources: |
- History and physical
- Progress notes
- Discharge summary
- Care Transition Record
- Consultation form
- Discharge planning form
- MOLST/POLST Forms
- Hospice referral
- Outpatient medical record
|
|---|
| Additional Notes: |
- Collected for both inpatient and outpatient
|
|---|
| Guidelines for Abstraction: |
|---|
| 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
|
- DNR orders
- Do Not Resuscitate Orders
|
|