Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of ACP Discussion:
Participants in the Discussion
List all participants in the ACP discussion, including the patient (if able), healthcare providers, family members, or healthcare proxies involved.
Initiating the Discussion
Briefly document who initiated the ACP discussion and the context for the conversation (e.g., routine visit, approaching illness, etc.).
Patient’s Values and Goals
Summarize the patient’s expressed values, beliefs, and goals regarding their future medical care.
This may include their preferences for pain management, life-sustaining treatments, and end-of-life care.
Information Provided
Document any educational materials or information provided to the patient about ACP options, such as advance directives, durable power of attorney for healthcare, or palliative care.
Decision-Making Capacity
Assess and document the patient’s decision-making capacity at the time of the discussion.
If a surrogate decision-maker is involved, document the reason for their participation.
Advance Directives
If an advance directive (living will, healthcare proxy) was completed or updated during the discussion, document its details and location within the medical record.
Plan
Outline the next steps in the ACP process.
This may include scheduling follow-up discussions, distributing copies of advance directives to relevant healthcare providers, or involving other specialists in the planning process.
Additional Considerations
Document any challenges or disagreements encountered during the discussion.
Mention if the patient prefers not to participate in ACP at this time.
Include any additional details specific to the patient’s situation or the ACP conversation.
Note:
ACP is an ongoing conversation, and these notes should be updated as the patient’s condition, values, or preferences change.
Ensure the documentation adheres to your facility’s guidelines and local regulations regarding ACP.