RPACE - documentation

1. Document ​​Identification Assessment
   Once you have identified that a patient would benefit from the Serious Illness Conversation, document your identification assessment outcomes in the "Advance Care Planning and Goals of Care Discussion Record."

   This document is found either inside or directly behind the Green Sleeve in the patient's paper chart​.

2. Document Conversation Outcomes
   Once you have started and/or completed the Serious Illness Conversation, document the conversation outcomes in the "Advance Care Planning and Goals of Care Discussion Record"​.​​

   This document is found either inside or directly behind the Green Sleeve in the patient's paper chart​.

Discussion records

These blank documents can be printed and added to the chart as needed

• ACP and GOC discussion record
• VGH Hospitalist Progr​am ACP-GOC record

​Additional education

Learning Hub e-Learning module #25247-- Documentation of Goals of Care in Paper Charts

​Identification and conversation outcomes in Long Term Care should be documented using whichever documentation system is used for all other documentation at a given site. 

If your site uses an electronic charting system, please follow the documentation practices at your site, which may include a focus heading such as "Goals of Care."  ​​

If your site uses paper charting, please use the "Advance Care Planning and Goals of Care Discussion Record" (VCH.0109).

This document is found either inside or directly behind the Green Sleeve in the patient's paper chart​. 

Indicate which assessment tool(s) you used to identify that the resident would benefit from a conversation and/or describe the changes in the resident that indicate that Goals of Care should be reviewed. 

Document the resident's (or Substitute Decision Maker's) responses to any of the 4 questions.​

Discussion record

This blank document can be printed and added to the chart as needed

• ACP and GOC discussion record

Additional education

Learning Hub e-Learning module #25247-- Documentation of Goals of Care in Paper Charts

​​Where do I document identification tools​?

• Surprise Question
• SPICT
• Clinical Frailty Scale​

Casenotes - Casenote reason: ongoing care, first contact note etc. (whatever is more appropriate)

​​Where do I document conversation?

• ​​​Serious Illness Co​​nv​ers​​ation​

Clinical care plan

• Need: Psychosocial
• Goal: Goals of care
• Intervention: Identify the client's wishes

Link casenote goals

​What template do I use to document?​

Goals of care documentation template (PARIS)

Copy and paste template into the Clinical Care Plan and​ Case Notes

Where do I document identification tools or conversations?

• Surprise Question
• SPICT
• Clinical Frailty Scale
• Serious illness conversation

Clinical care plan

• Need: Psychosocial
• Goal: Goals of care
• Intervention: Identify the client's wishes

What template do I use to document?

Goals of Care Documentation Template (PARIS – RAI Assessor)

Copy and paste template into the Clinical Care Plan

1. Enter social history/risk problem - SHx 99

   *Note that this Problem List including information about ACP gets shared into CareConnect*

2. Utilize encounter note
   *No further need to use either the Clinical Care Plan or Advance Care Plan Form*

   1. Title the heading of the encounter note “Advanced Care Plan/ Goals of Care"
   2. Type goc\ for the typing template and fill in the template

Identification assessment and conversation outcomes are documented in the Goals of Care Discussion power form.  This form can be accessed in two ways:

1. On the Patient Summary screen open the Handoff Tool and select the Advance Care Planning and Goals of Care workflow. Click on the blue arrow beside the Advance Care Planning and Goals of Care heading to open the Goals of Care Discussion power form. 
2. In the toolbar at the top of the screen, click on Ad Hoc Forms, and open the Assessments folder. Select Goals of Care Discussion and click Chart.

On the Goals of Care Discussion power form, complete each of the fields, including the Decision Maker involved in the conversation, the details of the conversation and the identification tools used.

Documented Goals of Care can be viewed on the Results Review screen on the Advance Care Planning tab.

Powerform tips – GOC/ACP/SDM/TDSM

Documentation of ACP and Goals of Care for Social Workers in CST - Instructional video​