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Differences in presenting advance directives in the chart, in the minimum data set, and through the staff's
Jiska Cohen-Mansfield1, Alexander Libin, Steven Lipson
1Research Institute on Aging, Hebrew Home of Greater Washington, Rockville, MD 20852, USA. cohen-mansfield@hebrew-home.org
The Gerontologist
|June 18, 2003
Summary
Advance directives documentation in nursing home charts varied by location. Agreement was higher between chart cover and internal documents than with the Minimum Data Set (MDS).
Area of Science:
- Gerontology
- Health Information Management
- Medical Ethics
Background:
- End-of-life care decisions rely on advance directives within nursing home resident charts.
- Information accessibility in charts is crucial but varies based on documentation quality and location.
- Limited research exists on how advance directives are collected and summarized in patient records.
Purpose of the Study:
- To investigate the summarization of advance directives within patient records.
- To explore physicians' perceptions of advance directives and formal orders.
- To compare the documentation of advance directives across different chart locations.
Main Methods:
- Study included 122 elderly residents from a large nursing home.
- Advance directive data were collected from three sources: Minimum Data Set (MDS), chart cover, and internal chart documents.
- Agreement rates between these sources were analyzed.
Main Results:
- Documented advance directive rates were higher than previously reported in literature.
- Agreement between sources varied depending on the specific directives and sources compared.
- Higher agreement was observed between internal chart documents and chart cover compared to MDS and other sources.
Conclusions:
- Discrepancies in advance directive documentation may stem from differing functions and procedures of source documents.
- Understanding these differences is key to improving the accessibility and reliability of end-of-life care information.
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