Documentation of Advance Directives in an Electronic Medical Record: A Learning Opportunity

Abstract

The discussion of patient preferences (advance directives) for their health care in an important component of their care across all health care settings. The extent of documentation of this discussion may vary in the Electronic Medical Record (EMR). Advance directives are particularly important when transferring from the hospital to subacute care. We conducted this study to evaluate the presence of an “Advance Directive” (AD) note in the EMR of patients discharging to skilled nursing facilities (SNFs). We further evaluated subtypes of the AD note and the relationship with comorbidity and one year mortality.