What should be documented in the chart regarding advance directives?

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Multiple Choice

What should be documented in the chart regarding advance directives?

Focus on whether an advance directive exists. Recording the existence of an advance directive in the chart ensures the care team knows if the patient has documented wishes that should guide decisions if they become unable to communicate. It helps honor the patient’s autonomy, provides legal protection for care decisions, and signals where the directive can be accessed when needed. It’s not about documenting family decisions or where a copy is kept at home; or assuming the patient has no directive unless stated. If no directive exists, that absence should be documented as such so the team knows there is no directive to follow.

Focus on whether an advance directive exists. Recording the existence of an advance directive in the chart ensures the care team knows if the patient has documented wishes that should guide decisions if they become unable to communicate. It helps honor the patient’s autonomy, provides legal protection for care decisions, and signals where the directive can be accessed when needed. It’s not about documenting family decisions or where a copy is kept at home; or assuming the patient has no directive unless stated. If no directive exists, that absence should be documented as such so the team knows there is no directive to follow.

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