Advance Care Planning

For Health care Professionals

Process for arriving at a Goals of Care Designation

Health care clinicians will have an advance care planning conversation with patients and their families. The goal of these conversations is as follows:

Ensure that the health care team understands the patient's goals, values and wishes regarding medical care.
Inform individuals regarding clinically appropriate interventions balanced with their individual wishes and goals.
Clarify the Goals of Care resulting in a Goals of Care Designation Order.

Workflow Process, Chart Forms and Tools

Process for arriving at a Goals of Care Designation includes three phases

Core Elements of Goals of Care Discussion

Chart Form: Advance Care Planning Tracking Record (AHS form #103152).
Used to document the outcome of the discussions related to advance care planning and a Goals of Care Designation.

Kept by the individual and will travel with them through the health care system.
Maintain current practice of putting the details of interactions with patients in the Progress or Interdisciplinary notes.

Advance Care Planning Charting Guidelines and Example document

Focus for Goals of Care

Cure or Control of condition with option for resuscitation (R Designations)
Cure or control of condition, no resuscitation (M Designation)
Alleviation of symptoms (C Designations)

Goals of Care Designation Order

Chart Form: Goals of Care Designation Order (AHS form #103547). Issued by the most responsible health care professional (usually a physician).

Order entered electronically wherever the Patient Care Information System (SCM) exists or on a paper form in all other care settings.
Copy of the order accompanies the patient upon transfer.

Advance Care Planning Charting Guidelines and Example document

Green Sleeve

Chart Form: Green Sleeve (AHS form #103299)

The Green Sleeve is a plastic pocket that is given to individuals receiving care from AHS, who have a non-R1 Designation, and/or who have had discussions related to advance care planning and Goals of Care Designations.
The Green Sleeve is kept by the individual and will travel with them through the health care system.
Individuals are asked to bring the Green Sleeve with them when they go the hospital or attend a clinic appointment.
If the person is admitted to a health care facility, the Green Sleeve will be placed in the health record.

Sector Specific Workflow Processes

Acute Care Inpatient Units (SCM Order Entry Units)

Acute Care Inpatient Units (NON-Electronic Order Entry Units)

Emergency Department

Ambulatory Care Units

Home Care

Long Term Care

Emergency Department - RURAL

Emergency Medical Services (EMS)

Designated Assisted Living

Advance Care Planning Home Current Highlights Advance Care Planning: Goals of Care Designation Policy Background Advance Care Planning Tools Goals of Care & Goals of Care Designations Forms & Processes Education Resources FAQ's Related Publications, Reports & Research Pediatrics Links Contact Us	Advance Care Planning For Health care Professionals Process for arriving at a Goals of Care Designation Sector Specific Workflow Processes Health care clinicians will have an advance care planning conversation with patients and their families. The goal of these conversations is as follows: Ensure that the health care team understands the patient's goals, values and wishes regarding medical care. Inform individuals regarding clinically appropriate interventions balanced with their individual wishes and goals. Clarify the Goals of Care resulting in a Goals of Care Designation Order. Workflow Process, Chart Forms and Tools Process for arriving at a Goals of Care Designation includes three phases Core Elements of Goals of Care Discussion Chart Form: Advance Care Planning Tracking Record (AHS form #103152). Used to document the outcome of the discussions related to advance care planning and a Goals of Care Designation. Kept by the individual and will travel with them through the health care system. Maintain current practice of putting the details of interactions with patients in the Progress or Interdisciplinary notes. Advance Care Planning Charting Guidelines and Example document Focus for Goals of Care Cure or Control of condition with option for resuscitation (R Designations) Cure or control of condition, no resuscitation (M Designation) Alleviation of symptoms (C Designations) Goals of Care Designation Order Chart Form: Goals of Care Designation Order (AHS form #103547). Issued by the most responsible health care professional (usually a physician). Order entered electronically wherever the Patient Care Information System (SCM) exists or on a paper form in all other care settings. Copy of the order accompanies the patient upon transfer. Advance Care Planning Charting Guidelines and Example document Green Sleeve Chart Form: Green Sleeve (AHS form #103299) The Green Sleeve is a plastic pocket that is given to individuals receiving care from AHS, who have a non-R1 Designation, and/or who have had discussions related to advance care planning and Goals of Care Designations. The Green Sleeve is kept by the individual and will travel with them through the health care system. Individuals are asked to bring the Green Sleeve with them when they go the hospital or attend a clinic appointment. If the person is admitted to a health care facility, the Green Sleeve will be placed in the health record. Sector Specific Workflow Processes Acute Care Inpatient Units (SCM Order Entry Units) Acute Care Inpatient Units (NON-Electronic Order Entry Units) Emergency Department Ambulatory Care Units Home Care Long Term Care Emergency Department - RURAL Emergency Medical Services (EMS) Designated Assisted Living
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