Specifications Manual for Joint Commission National Quality Measures (v2020B)
Posted: 2/5/2020
Home » Discussion of Advance Directives/Advance Care Planning

Release Notes:
Data Element
Version 2020B

Name:Discussion of Advance Directives/Advance Care Planning
Collected For: ACHF-04, ACHFOP-06
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.
Question:Was documentation present in the medical record of a one-time discussion of advance directives/advance care planning with a healthcare provider?
Format:
Length:1
Type:Alphanumeric
Occurs:1
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.
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”.
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:
Guidelines for Abstraction:
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

None

Discussion of Advance Directives/Advance Care Planning
CPT® only copyright 2019 American Medical Association. All rights reserved.
Specifications Manual for Joint Commission National Quality Measures (v2020B)
Discharges 07-01-20 (3Q20) through 12-31-20 (4Q20)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

CPT® only copyright 2019 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.

^