Advanced Directives Policy and Implementation Guidelines for Oral Surgery Practices

Purpose

To establish standardized procedures for handling advanced directives in the oral surgery setting and ensure compliance with state and federal regulations while respecting patient autonomy.

Policy Statement

This practice acknowledges and honors patients' rights to make informed decisions about their medical care, including the right to accept or refuse treatment and to formulate advanced directives.

Procedures

1. Documentation Requirements

• Request and document the existence of advanced directives during initial patient registration
• Maintain copies of advanced directives in patient's electronic health record
• Update documentation annually or as patients modify their directives

2. Staff Responsibilities

Front Office Staff

• Request advanced directive documentation during registration
• Scan and attach documents to patient records
• Flag charts with appropriate indicators

Clinical Staff

• Review advanced directives before procedures
• Confirm current status with patient
• Document any changes or modifications

3. Implementation Protocol

1. Initial Patient Contact

   • Provide advanced directive information packet
   • Document patient's response
   • Obtain copies of existing directives

2. Pre-Procedure Review

   • Verify directive status
   • Confirm with patient and family
   • Note any limitations or specifications

3. Emergency Situations

   • Follow directive specifications unless invalidated by state law
   • Document any deviations and rationale

Legal Considerations

• Comply with state-specific requirements
• Maintain confidentiality
• Update policies as regulations change

Review and Updates

• Annual policy review required
• Staff training documentation
• Compliance monitoring

Appendix

Required Forms

1. Advanced Directive Acknowledgment Form
2. Patient Rights and Responsibilities
3. Annual Review Documentation
4. Staff Training Log