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RPACE - Documentation

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Documenting Identification Assessment & Serious Illness Conversation Outcomes

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.

Blank Document (can be printed and added to chart as needed):

ACP and GOC discussion record.pdf

VGH Hospitalist Program ACP-GOC record

"Advance Care Planning and Goals of Care Discussion Record" charting example:


 

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.

Blank Document (can be printed and added to chart as needed):

ACP and GOC discussion record.pdf

"Advance Care Planning and Goals of Care Discussion Record" charting example: 


 

Where do I document 
Identification tools?

  • Surprise Question
  • SPICT
  • Clinical Frailty Scale



Where do I document 

Conversation?

  • Serious Illness Conversation

What template do I use to document?

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


  Link casenote goals


 

CASENOTE REASON: ongoing care, first contact note etc. (whichever is most appropriate)



NEED: Psychosocial
GOAL: Goals of Care
INTERVENTION: Identify Client’s Wishes

 

Where do I document 
Identification tools?

  • Surprise Question
  • SPICT
  • Clinical Frailty Scale



Where do I document
Conversation?

  • Serious Illness Conversation


What template do I use to document?

Copy and paste template into the Clinical Care Plan



















NEED: Psychosocial
GOAL: Goals of Care
INTERVENTION: Identify Client’s Wishes

This  allows for the  creation of a Clinical Care Plan right after the completion of an RAI-HC Assessment  and is more suited to the RAI Assessor’s workflow





 

Where do I document Identification tools?

  • Surprise Question
  • SPICT
  • Clinical Frailty Scale


Where do I document 
Conversation?

  • Serious Illness Conversation

What template do I use to document?

Copy and paste template into the ACP/ GOC Form








 

Advance Care Plan (ACP)/ Goals of Care (GOC) Form


Ensure ‘Advance Care Plan’ is included in the Problem List under Social/ Risk. This will be shared into Care Connect

See Screenshots for further guidance, click here

 

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, 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.


SOURCE: RPACE - Documentation ( )
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