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J Palliat Care. 2019 Jul 7:825859719860129. doi: 10.1177/0825859719860129. [Epub ahead of print]

Documentation of Advance Directives and Code Status in Electronic Medical Records to Honor Goals of Care.

Author information

1
1 Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Omaha, NE, USA [Advocacy project took place in the location Division of Pediatric Palliative Care, Children's Hospital and Medical Center Omaha, Omaha, NE, USA.].
2
2 Department of Information Technology, Children's Hospital and Medical Center Omaha, Omaha, NE, USA.
3
3 Children's National Health System, Washington, DC, USA.
4
4 Division of Adolescent and Young Adult Medicine, Center for Translational Science/Children's Research Institute, Children's National Health System, Washington, DC, USA.
5
5 Department of Pediatrics, Children's National Health System, George Washington School of Medicine and Health Sciences, Washington, DC, USA.

Abstract

Advance care planning is a process that supports conversations about the values that matter most to patients and their family members. The documentation of advance directives and code status in a patient's electronic health record (EHR) is a critical step to ensure treatment preferences are honored in the medical care received. The current approach to advanced care planning documentation in electronic medical records often remains disparate within and across EHR systems. Without a standardized format for documentation or centralized location for documentation, advance directives and even code status content are often difficult to access within electronic medical records. This case report launched our palliative care team into partnership with the Information Technology team for implementation of a centralized, standardized, longitudinal, functional documentation of advance care planning and code status in the electronic medical record system.

KEYWORDS:

advance care planning; electronic health record; information technology; pediatric palliative

PMID:
31280659
DOI:
10.1177/0825859719860129

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