8. Documenting, Filing, & Rescinding (7 minutes) Slide 14 SAY: So far we have talked about staff responsibilities, what to tell patients about advance directives, and various forms and educational materials. Now we are going to talk about the nuts and bolts of implementing advance directives, including documenting, filing, and rescinding. Only three note titles are approved for documenting advance directives and advance care planning discussions in the health record. They are Directive,” “Advance Directive Discussion,” and Advance “Advance “Rescinded Directive.” All three note titles must be linked to Crisis Warnings Allergies Directives (CWAD) postings in the Computerized Patient Record System (CPRS). The note title is used only to indicate “Advance Directive” that an advance directive document has been entered into the electronic record. An note is “Advance Directive” generated automatically when an advance directive is completed via iMedConsentTM. The “Advance Directive” note title is also used when an advance directive is scanned into the electronic record. Staff who conduct advance care planning discussions with patients should use the Directive “Advance Discussion” note title to document their discussions. If the discussion pertains to a particular advance directive that was already in the health record, an addendum to the relevant “Advance Directive” note may also be used to document the discussion. The Advance note title is used to “Rescinded Directive” document the revocation of an advance directive patient’s and the invalidity of the associated directive. We will be going over these procedures next. CLICK.
8. Documenting, Filing, & Rescinding (7 minutes) Slide 14 SAY: So far we have talked about staff responsibilities, what to tell patients about advance directives, and various forms and educational materials. Now we are going to talk about the nuts and bolts of implementing advance directives, including documenting, filing, and rescinding. Only three note titles are approved for documenting advance directives and advance care planning discussions in the health record. They are “Advance Directive,” “Advance Directive Discussion,” and “Rescinded Advance Directive.” All three note titles must be linked to Crisis Warnings Allergies Directives (CWAD) postings in the Computerized Patient Record System (CPRS). The “Advance Directive” note title is used only to indicate that an advance directive document has been entered into the electronic record. An “Advance Directive” note is generated automatically when an advance directive is completed via iMedConsentTM. The “Advance Directive” note title is also used when an advance directive is scanned into the electronic record. Staff who conduct advance care planning discussions with patients should use the “Advance Directive Discussion” note title to document their discussions. If the discussion pertains to a particular advance directive that was already in the health record, an addendum to the relevant “Advance Directive” note may also be used to document the discussion. The “Rescinded Advance Directive” note title is used to document the patient’s revocation of an advance directive and the invalidity of the associated directive. We will be going over these procedures next. CLICK.
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