Cumplimiento en centros sanitarios 11 elementos
Advance Directives & Informed Consent Audit
Esta lista de verificación está en inglés.
Audit of advance directive and informed consent practices covering inquiry and documentation of directives, patient rights notice, informed consent elements, and surrogate decision-making.
Patient Self-Determination ActCMS 42 CFR 482.13(b)42 CFR 489.102TJC RI.01.05.01
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Advance Directive Inquiry & Notice
- Is each adult patient asked at admission whether they have an advance directive, and is the response documented in the record? *
- Is written information provided about the patient's rights under state law to make health care decisions and formulate advance directives? *
- Is care provided without conditioning it on whether the patient has executed an advance directive? *
Directive Documentation & Honoring
- Is a copy of the advance directive (living will, healthcare power of attorney, POLST/MOLST) placed in the medical record? *
- Is code status clearly documented and accessible to the care team, with orders reflecting the directive? *
- Are staff educated on honoring advance directives and community education provided as required? *
Informed Consent Elements
- Does informed consent document the nature of the procedure, material risks, benefits, and reasonable alternatives? *
- Is the consent signed by the patient or authorized representative and the practitioner, and dated before the procedure? *
- Are language and communication needs addressed (interpreter services) so consent is truly informed? *
Surrogate & Capacity
- When a patient lacks decision-making capacity, is the authorized surrogate identified per state law and documented? *
- Is a capacity assessment documented when there is a question about the patient's ability to consent? *
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