Printer Friendly, PDF & Email

Advance Directives

Data Element

Information from the submission form

Advance Directive Observation
Description
In the context of a Patient Summary or Encounter Summary authored by a clinician or assembled by clinician’s EMR system, observations verifying a patient’s advance directive information and medical orders for life-sustaining treatments are available and have been reviewed using established standards for recording this type of information documented by providers.In a Patient Summary or Encounter Summary, Advance Directive Observations indicate if a person has a Personal Advance Care Plan, where the current source document can be referenced, if it was verified, and optional observations about what types of wishes the patient has expressed in his or her generated advance directive information, and if the person’s advance directive documentation has been verified. The set of recognized types of content include concepts from the value set: Advance Directives Content Type SCT urn:oid:2.16.840.1.113762.1.4.1115.5 which is openly available for reference in the National Library of Medicine’s Value Set Authority Center. It can be referenced using this url: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1115.5/definition

Comment

Adv Directives Overall

Advance Directives are the original patient goals. They represent goals that are pervasive and used every day to help define the level of care a patient wants and to amplify their own voice in care. Whether the goals are for all extraordinary measures or comfort care, instructions and wishes, the advance directive is the original and ubiquitous personal care plan. It is encouraging to see the data elements defined in USCDIv2 L1 as being so consistent with efforts in the industry, and current industry practice. PACIO, MITRE, HL7 efforts have consistently recommended the same elements.  Adoption of Advance Directives should be considered in USCDI V2. 

Log in or register to post comments