Co Authors: Kara Bischoff & Sirisha Naranaya

Background:

Advanced care planning documentation is recognized as an important tool allowing patients to direct the type and intensity of medical care they receive. Systematic and educational innovations over the past decade have been effective at increasing the conversations around advanced care planning as well as the numbers of completed advanced care planning documents such as advanced directives (AD) and Physician Orders for Life Sustaining Treatments (POLSTs). 

Objective:

The goal of our proposal is to standardize advance care planning documentation and to create a centralized location in the chart for this documentation that is easily accessible across settings and to all clinicians caring for a patient. 

Description:

We reached out to a broad group of stakeholders across many disciplines and work areas including Primary Care, Oncology, Symptom Management, Home Based Primary Care, Housecalls, Population Health, Inpatient Palliative Care, and the Transitional Care and Heart Failure Program and identified the following needs:  

1. Standardized Documentation: Templates and/or dot phrases to guide documentation of best practices for advance care planning
2. A Central Location: One universally accessible location, such as a tab in Chart Review, where all inpatient and outpatient goals of care conversations and advance care planning documents can be quickly and easily found. Given the need for communication across transitions, a central location could also ensure that this documentation could be easily shared with partnering facilities across transitions in care.
3. Clear Display of Key Information: A prominent location in the current outpatient workflow tohighlight important information, such as patients’ surrogate decision-makers andprevious code status orders, in a visually prominent place in ApeX across all care settings (e.g. devotinga portion of the “Snapshot” to Advanced Care Planning)
4. Accessibility of Information Across Care Settings and Disciplines: Ensure that clinicians from all disciplines have the ability to document information about goals of care and advance care planning and have access to the same information.
5. Discharge Summary: Improve documentation of goals of care in hospital discharge summaries

Based on these needs we propose the following interventions:

1. Standardized Documentation: Improve templates and/or dot phrases to guide documentation of goals of care: 

• Create a dot phrase and/or note template for use in the Code Status and Advanced Directives note type
• Create a dot phrase that can be used in the overview of Problem List problems “Goals of Care Counseling and Discussion” and “Advanced Care Planning”
• Make these notes accessible to multiple disciplines, including social workers and nurse

2. Chart Review Tab: Create a central location where inpatient and outpatient goals of care conversations can be found

• Change the tab in Chart Review from “AD/POLST/Legal” to “ACP/AD/POLST” or to “GOC Documentation”
• Within this tab include:
• All notes with the “Patient Care Conference” or “Code Status and Advanced Directives” note type
• Problem List notes for the “GOC Counseling and Discussion” and “Advanced Care Planning” problems
• Consider inclusion of “Significant Event” notes
• Consider creating a new note type called “Goals of Care and Advance Care Planning”, which could be templated as above, to use for all such discussions
• File scanned ADs and POLST documents in this tab

3. Snapshot: Create a section of the “Snapshot,” commonly used in the outpatient setting, where the presence of ADs, POLSTs and prior inpatient Code Status can be quickly seen (this is present in the banner bar in the inpatient setting). Make sure this is present for all clinical disciplines in all settings.

4. Discharge Summary: Improve the “Expressed Wishes” section of the current inpatient discharge summar

• Make this documentation synergistic with documentation in the Problem List, ideally by pulling in the overview of the “GOC Counseling and Discussion or “Advanced Care Planning” Problem List notes.

5. Audit and Feedback: A report has already been created that allows us to audit inpatient documentation of advanced care planning. This will be used to feed data back to teams.