Treatment Preferences Document (v2019A)

Specifications Manual for Joint Commission National Quality Measures (v2019A)

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Release Notes:
Data Element
Version 2019A

Name:

Treatment Preferences Document

Collected For:

PAL-05

Definition:

Patients preference regarding goals of care and treatment preferences are documented and accompany the patient to the next level of care at the time of discharge from the hospital.

Question:

Was a transition of care document detailing goals of care and treatment preferences developed and did it accompany the patient to the next level of care at the time of discharge?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

1 Yes, there is documentation in the medical record that a transition of care document detailing goals of care and treatment preferences was developed and sent with the patient at the time of discharge.

2 There is documentation in the medical record that the organization attempted either to have the discussion or complete the document but patient and/or responsible party declined.

3 No, a transition of care document detailing goals of care and treatment preferences was not developed and/or was not sent with the patient at the time of discharge, or unable to determine from medical record documentation.

4 Patient expired prior to discharge.

Notes for Abstraction:

Documented treatment preferences, as appropriate to the patient's condition, may include, but are not limited to:
- Blood transfusion
- CPR preference
- Dialysis
- Hospitalization or transfer preference
- Intravenous [IV] fluids
- Mechanical ventilation
- Surrogate decision maker
- Tube feeding
- Use of antibiotics
Goals of care may be curative, rehabilitative, life-prolonging, or comfort focused.
Any documentation in the medical record that the document was given to the patient and/or sent to the next care setting or provider may be used to select "1". This documentation is NOT restricted to the palliative care team.
If a document was previously completed prior to this admission there must be documentation of a conversation that the document continues to reflect the patients’ treatment preferences and care goals.
If documentation is not clear that the treatment preferences document was sent with patient at discharge, select “3.”
Documentation must include both the patient’s preference regarding goals of care and treatment preferences in order to select “1.” For example: "patient's goal is to attend their daughter's wedding in 4 months, wishes to continue with all treatments and full code status"; "patient wants to be kept comfortable; DNR, no tube feedings, IVs or return to hospital."
“Responsible party” refers to the legally responsible or authorized individual, such as the Health Care Power of Attorney or legal guardian. In cases where there is no legal guardian or power of attorney identified, the organization should use state law guidance to identify the appropriate surrogate decision-maker.

Suggested Data Sources:

Advanced directives
Discharge summary
Care transition record
Discharge planning form
State specific patient treatment preferences forms

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Advance care plan
Advance decision
Advance directive
Advance healthcare directive
Goals of care
Health care proxy
Living will
Personal directive
Power of attorney for healthcare
Treatment preferences
State specific treatment preference forms may include:
- COLST (Clinician Orders for Life Sustaining Treatment)
- MOLST (Medical Orders for Life-Sustaining Treatment)
- MOST (Medical Orders for Scope of Treatment)
- POLST (Physician/Practitioner Orders for Life-Sustaining Treatment)
- POST (Physician Orders for Scope of Treatment)
- TPOPP (Transportable Physician Orders for Patient Preferences)

None

Specifications Manual for Joint Commission National Quality Measures (v2019A)
Discharges 07-01-19 (3Q19) through 12-31-19 (4Q19)

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