Advance Care Planning Discussion Note

Date/Time of Discussion: [Date and time of ACP discussion]

Setting: [clinic / inpatient / telehealth / home visit / other: specify]

Participants: [Patient participation status]; [Names and relationships of other participants]; [Interpreter used: yes/no; language if applicable]; [Voluntary participation statement: ACP discussion offered; patient agreed and participated voluntarily / declined / deferred]. (If patient declined, briefly document reason if stated and plan to revisit.)

Decision-Making Capacity & Decision-Maker

Capacity for ACP decisions today: [yes / no / partial / fluctuating / unable to assess]. (If capacity is limited, briefly state clinical basis and steps taken to maximize participation.)

Decision-maker: [patient (self) / agent or proxy via advance directive / court-appointed guardian / default surrogate per state hierarchy]. Authority source: [document reviewed / per patient report / per family report / unknown]. [Name, relationship, and contact information if surrogate].

Surrogate status: [identified / not identified]. (If not identified, document plan to address.)

Disagreements: [Description and resolution plan]. (Include only if disagreements exist.)

(Never omit capacity and decision-maker documentation. If unknown, state what is unknown and follow-up plan.)

Discussion Summary

[Reason for ACP discussion: clinical trigger such as new serious diagnosis, acute deterioration, pre-procedure planning, patient request, or routine care; what decisions were being considered; if revisiting prior decisions, note what has changed]

[Medical context shared that meaningfully informed decisions: key diagnoses and trajectory, treatment options, clarifications of misconceptions]

[Patient goals, values, and preferences: what matters most, acceptable and unacceptable outcomes, tradeoffs and priorities, cultural or spiritual considerations, preferred decision-making style; include brief direct quote if it captures core values]. (Do not infer goals from diagnoses; attribute to patient, surrogate, or prior documentation.)

Decisions Made

Code status: [Attempt CPR: yes / no (DNAR/DNR) / deferred]. (If deferred, document reason and planned follow-up timeframe.)

Other treatment preferences discussed: [Document each intervention addressed with decision: yes / no / time-limited trial / conditional / deferred; for time-limited trials, specify duration or milestone, success criteria, and reassessment plan]. (Include only treatments actually discussed. Avoid ambiguous terms like "no heroic measures" unless immediately defined with specific decisions.)

Comfort-focused care clarifications: [State what comfort measures and appropriate treatments will be provided to ensure DNAR is not misinterpreted as do-not-treat]. (Include when comfort-focused approach is chosen.)

Documents, Orders & Follow-Up

Advance directive: [reviewed / completed / updated / discussed only / not addressed]; [Location: scanned to EHR / provided to patient / provided to surrogate / unknown].

POLST/MOLST: [completed / updated / reviewed / not applicable / not addressed]; [Location if applicable].

Orders placed: [code status order / comfort-measures order set / hospice referral / palliative care consult / none]. (If none, state why and plan.)

Notifications: [Who was notified: primary team, nursing, facility staff, surrogate, etc.].

Follow-up actions: [Action items with responsible person and timing or trigger for each].

Billing Attestation (if applicable)

[ACP time: total minutes] ([start time–end time]), [face-to-face / telehealth]. Discussion voluntary. Participants: [list]. Time reflects ACP discussion only and did not overlap with other time-based services. (Include only when billing ACP services.)

Clinician Signature: [Name, role, credentials] — [Date/time signed]