Our team is noticing inconsistencies in documentation of the Advance Directive process during admission during medical record review. Organizations are expected to take reasonable steps to determine the patient’s wishes in the designation of a representative to exercise the patient’s right to participate in the development and implementation of the patient’s plan of care. This designation, in the form of an Advance Directive, is often solicited during the admission process to ensure the healthcare team is aware of the patient’s wishes. If the patient does not have an Advance Directive, it is expected that the patient is provided with written information about the organization’s policies regarding the right to formulate an advance directive.
Our observations from the field include:
- The Admissions clerk documents that the patient has an Advance Directive but no documentation that the directive is retrieved and placed on the chart per policy.
- Documentation that the patient does not have an Advance Directive and there is a lack of documentation that the patient was provided information on how to formulate one.
- Missing documentation that the patient was ever asked if they had an Advanced Directive.
- Duplicative query for Advance Directive information during the nursing admission process with similar gaps in documentation as noted above.
We recommend that organizations review their Advance Directive policy and process and determine if opportunities exist, as shown in our observations above. Furthermore, streamlining the process should be considered to reduce duplication of effort. Proactive action to ensure that the Advance Directive process is sound will help avoid a scramble when patients cannot advocate for themselves and documentation designating a representative is missing due to administrative oversight.
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Courtemanche & Associates specializes in Healthcare Accreditation and Regulatory Compliance Consulting Services. With over 30 years of being in business and 100+ years of healthcare experience amongst our consulting team, we are ready to assist with your accreditation and regulatory compliance needs.
