Family Meeting Documentation Audit

Audit family meeting documentation in the chart for clear recording of attendees, goals-of-care discussion, decisions reached, and follow-up plan.

Audit Details

• Encounter date and chart location documented
  Record the date of the family meeting and where the note appears in the chart.
• Meeting type clearly identified
  Identify whether this was a family meeting, goals-of-care discussion, care conference, or similar encounter.
• Auditor identified chart reviewed
  Document the chart, note, or encounter reviewed for this audit.

Attendees and Roles

• Patient or surrogate participation documented
  Confirm the note identifies whether the patient participated directly or a surrogate/family decision-maker was present.
• Clinical attendees listed by name and role
  Attending clinicians should be identifiable by name and role, such as physician, nurse, social worker, chaplain, or case manager.
• Family members or other participants documented
  Confirm the note includes other participants who were present or involved in the discussion.
• Decision-maker or legal surrogate identified when applicable
  If the patient lacked capacity or a surrogate participated, the note should identify the decision-maker when appropriate.

Discussion Content

• Reason for meeting documented
  The note should state why the meeting occurred, such as clinical update, prognosis review, treatment options, or goals-of-care clarification.
• Clinical status or prognosis summarized
  Confirm the note summarizes the patient’s current condition, prognosis, or key clinical issues discussed.
• Options, risks, and benefits documented
  The note should reflect the major treatment options discussed, including relevant risks, benefits, or burdens.
• Questions, concerns, or values expressed by family documented
  Confirm the note captures family questions, concerns, patient values, or stated priorities that influenced the discussion.

Decisions and Plan

• Decisions reached clearly documented
  The note should clearly state any decisions made during the meeting, including treatment direction or code status changes if applicable.
• Follow-up plan documented with responsible party
  The note should include next steps, timing, and who is responsible for follow-up actions.
• Consults, referrals, or orders referenced when applicable
  Confirm the note references any ordered consults, referrals, or care plan changes resulting from the meeting.
• Communication plan to patient and family documented
  The note should indicate how the plan will be communicated or reinforced with the patient and family.

Documentation Quality and Compliance

• Documentation is timely and signed by author
  The note should be entered promptly and authenticated according to facility policy.
• Note is objective, clear, and free of ambiguous language
  Assess whether the documentation is concise, factual, and understandable to other care team members.
• Deficiencies or missing elements documented for follow-up
  If any required elements are missing, record the deficiency and any recommended corrective action.