Center for Improvement in Healthcare Quality Newsletter
July 2022

CIHQ-ARS Blog

Advance Directives – What You Should Know

By: Ann Martin
Are you prepared to correctly answer your patient’s questions regarding Advance Directives? Not sure what to do, how important it is, and what is the best way to assist the patient/family. Hospital staff struggle at times with what to assess and document to meet this regulatory requirement. The following guidance should be used when staff assess for the presence of an advance directive and what should be documented to meet the requirements.
Inpatient Requirements
  • On admission the patient will be informed of their right to formulate and execute an advance directive and be provided with a copy of the notice on the organization’s policy/process. This process should occur at registration or shortly thereafter.
  • If the patient/family does not have an advance directive and requests one, provide them with information on how to formulate and execute an advance directive and assist the patient/family in completing the directive. Document it in the medical record.
  • If the patient has a written advance directive present, place a copy in the patient’s medical record.
  • If the patient has a written advance directive but it is not provided at the time of admission, ask the patient/family to provide a copy to be placed in the patient’s medical record.
  • If the patient makes a verbal advance directive, document it in the patient medical record.
  • Notify the patient’s attending and/or supervising physician. The physician should then discuss the directive with the patient and provide appropriate treatment orders. Discussion and orders shall be documented in the medical record.
Outpatient And Ambulatory Care Setting Requirements
  • Provide the notice of advance directive policy to outpatients (or their representatives) that are in the emergency department, who are in an observation status, or who are undergoing same-day surgery.
  • Make available information on their right to formulate and execute an advance directive and provide information to them upon their request.
Patients with decision-making capacity have the right to formulate and execute advance healthcare directives. They have the right to:
  • Designate an agent to make health care decisions on their behalf through execution of a Durable Power of Attorney for Healthcare (DPAHC)
  • Designate a surrogate to make medical decisions on their behalf while receiving care and services
  • Formulate directives in writing, verbally, or both
  • Review, change or modify their directive(s) at any time either in writing, verbally, or both
  • Be informed of the extent to which the organization is either unable or unwilling to honor a directive
The requirement of each organization is to honor a patient’s directive to the extent permitted by law and organization policy. The information provided in this article are basic tips to assist staff in meeting the regulatory requirements and what is commonly missed and cited during surveys.
References
CMS Conditions of Participation for Acute Care Hospitals, §482.13(a) & §482.13(b)
CMS Conditions of Participation for Critical Access Hospitals §485.608(a)
Center for Improvement in Healthcare Quality, Standard PR-6
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