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: