Purpose
To establish standardized procedures for discussing, documenting, and maintaining advance directives in accordance with state laws and medical best practices.
Scope
This policy applies to all clinical staff members within the Internal Medicine practice.
Policy Components
1. Initial Patient Contact
- Ask all new patients aged 18 and older about existing advance directives
- Document presence or absence in designated EMR field
- Request copies of existing documents for medical record
2. Required Documentation
- Living Will
- Durable Power of Attorney for Healthcare
- Do Not Resuscitate (DNR) orders, if applicable
- POLST/MOLST forms, where state-mandated
3. Staff Responsibilities
Front Desk Staff
- Provide advance directive information packets to new patients
- Maintain current state-specific forms
- Document receipt of information in EMR
Clinical Staff
- Review advance directive status annually
- Facilitate completion of forms when requested
- Ensure proper witnessing of documents
- Update EMR documentation
Physicians
- Discuss advance care planning during Medicare Annual Wellness Visits
- Document all advance care planning discussions
- Verify understanding of patient wishes
- Sign relevant forms as required
4. Storage and Accessibility
- Scan documents into EMR within 24 hours
- Flag advance directives for easy access
- Maintain original documents in designated section of chart
- Review accessibility during quarterly audits
5. Updates and Reviews
- Annual review of advance directive status
- Updates prompted by:
- Change in health status
- Change in marital status
- Death of designated healthcare proxy
- Patient request
Compliance Requirements
- All staff must complete annual training
- Quarterly audits of documentation compliance
- Annual policy review and updates
Related Forms
- Advance Directive Information Packet
- State-specific directive forms
- Documentation checklist
- Annual review form