Release Notes:
Data Element
Version 2018B1
| Name: | Discussion of Advance Directives/Advance Care Planning |
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| Collected For: |
ACHF-04, ACHFOP-06 |
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| Definition: | Documentation in the medical record of a one-time discussion of advance directives/advance care planning with a healthcare provider. Advance directives are instructions given to 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. |
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| Question: | Was documentation present in the medical record of a one-time discussion of advance directives/advance care planning with a healthcare provider? |
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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 was documentation present in the medical record of a one-time discussion of advance directives/advance care planning with a healthcare provider.
N (No) There was no documentation present in the medical record of a one-time discussion of advance directives/advance care planning with a healthcare provider, or unable to determine from medical record documentation.
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| Notes for Abstraction: |
- If documentation of a discussion of advance directives or advance care planning with the patient and/or caregiver is present in the medical record, select “Yes”.
- The caregiver is defined as the patient's family or other person (e.g. home health, VNA provider, prison official or law enforcement personnel) who will be responsible for care of the patient after discharge.
- Advance directive discussion may be with a physician/APN/PA, social worker, pastoral care, or nurse.
- A one-time discussion documented anywhere in the medical record is sufficient to select “Yes” for this data element.
- 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.
- Documentation that the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan, select “Yes”.
- Documentation that the patient's cultural beliefs may be in conflict with the discussion of advance directives, e.g., Navajo Indian, select “Yes”.
- Documentation of patient/family refusal of a discussion, select “Yes”.
- If an advance directive is present in the medical record, select “Yes”.
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| 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
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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
- DNR orders
- Do Not Resuscitate Orders
- 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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None |
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