Advance Care Planning Documentation Practices and Accessibility in the Electronic Health Record: Implications for Patient Safety

J Pain Symptom Manage. 2018 Feb;55(2):256-264. doi: 10.1016/j.jpainsymman.2017.09.018. Epub 2017 Sep 22.


Context: Documenting patients' advance care planning (ACP) wishes is essential to providing value-aligned care, as is having this documentation readily accessible. Little is known about ACP documentation practices in the electronic health record.

Objectives: The objective of this study was to describe ACP documentation practices and the accessibility of documented discussions in the electronic health record.

Methods: Participants were primary care patients at the San Francisco Veterans Affairs Medical Center, were ≥60 years old, and had ≥2 chronic/serious health conditions. In this cross-sectional study, we assessed the prevalence of ACP documentation, including any legal forms/orders and discussions in the prior five years. We also determined accessibility of discussions (i.e., accessible centralized posting vs. inaccessible free text in progress notes).

Results: The mean age of 414 participants was 71 years (SD ± 8), 9% were women, 43% were nonwhite, and 51% had documented ACP including 149 (36%) with forms/orders and 138 (33%) with discussions. Seventy-four participants (50%) with forms/orders lacked accompanying explanatory documentation. Most (55%) discussions were not easily accessible, including 70% of those documenting changes in treatment preferences from prior forms/orders.

Conclusion: Half of chronically ill, older participants had documented ACP, including one-third with documented discussions. However, half of the patients with completed legal forms/orders had no accompanying documented explanatory discussions, and the majority of documented discussions were not easily accessible, even when wishes had changed. Ensuring that patients' preferences are documented and easily accessible is an important patient safety and quality improvement target to ensure patients' wishes are honored.

Keywords: Advance care planning; advance directive; documentation accessibility; electronic health record; patient safety; primary care.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Advance Care Planning*
  • Aged
  • Chronic Disease / therapy
  • Cross-Sectional Studies
  • Documentation*
  • Electronic Health Records*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Patient Safety
  • Patient-Centered Care
  • Primary Health Care
  • Retrospective Studies
  • Veterans