*DT201* DT201

0506 FL
PROOF 3
3/4/11
ADVANCE DIRECTIVE
ASSESSMENT

Admission Date: ___________________________

Does the patient have an ADVANCE DIRECTIVE?

(Once "shaded box" filled in then process completed) Date Time Initials

M No and not interested Process Complete

M No but wishes to receive information- Advance Directive Follow-up Needed

information given (follow-up needed) (Nurse)

M Patient Not interested in completing Advance Directive at this time after

information given Process Complete

M Patient completed new Advance Directive and placed in chart Process Complete

M Patient needs help completing Advance Directive- refer to Social Worker Follow-up Needed
(follow-up needed) (Social Worker)

M Social Worker Follow-up- Patient Not interested in completing Advance

Directive at this time after information given Process Complete

M Social Worker Follow-up- Patient completed new Advance Directive and

placed in chart Process Complete

M YES and Advance Directive IS on the chart: validate as signed,

witnessed and dated Process Complete

M YES and Advance Directive IS NOT on the chart: Attempt to obtain Follow-up Needed
from previous medical record (refer to Social Worker) (Social Worker)

M Social Worker Follow-up- Previous Advance Directive obtained and

validated with patient, and placed in chart. Process Complete

M Social Worker Follow-up- Previous Advance Directive unable to be obtained.

Patient completed new Advance Directive and placed in chart. Process Complete

M Social Worker Follow-up- Previous Advance Directive unable to be obtained.

Patient not interested in completing Advance Directive at this time after
information given. Process Complete

M YES and Advance Directive IS NOT on the chart: Requested to be Follow-up Needed
brought in within 24 hours (Nurse)

Follow-up Needed
M Second request for Advance Directive to be brought in.
(Nurse)

Follow-up Needed
M Third request for Advance Directive to be brought in- refer to Social Worker
(Social Worker)

M Patient unable to respond and/or after 24 hours no family or significant Follow-up Needed
other is available - refer to Social Worker (Social Worker)

Initials Signature Title Initials Signature Title

AH9907355 (03/11)