Advance Directive Review and Update

This template is for nursing home administrators, directors of nursing, charge nurses, social workers, and clinical leaders who review resident end-of-life documentation. It also works for compliance staff who need a repeatable audit trail. The reviewer should be someone who can verify the chart, confirm resident or representative participation, and escalate discrepancies. In many facilities, the clinical leader signs off on any required follow-up.

Use it on admission, at scheduled periodic reviews, and whenever there is a change in condition, goals of care, code status, or legal representative. It is also useful after hospital return, hospice enrollment, or a family meeting that changes preferences. The template is designed for recurring audits, not a one-time intake form. Facilities often pair it with care plan review cycles and annual documentation checks.

It covers code status, healthcare proxy or durable power of attorney for health care, living will or equivalent advance directive, and DNR or related resuscitation orders when applicable. It also checks that the most recent version is clearly identified and that signatures and dates are present where required. The goal is to confirm the record is complete enough for staff to act on without delay. If a document type is not applicable, the template should capture that clearly rather than leaving it blank.

The template supports documentation practices expected under long-term care survey standards, resident rights requirements, and facility policies on informed decision-making. It also aligns with broader healthcare recordkeeping expectations and emergency readiness practices. It does not replace legal review, but it helps show that the facility checked whether the resident’s documented wishes are current and accessible. If state law has additional forms or witness requirements, those can be added to the template.

Common findings include an outdated code status, a proxy form that is missing signatures, and a DNR order that is present in one location but not easy to find in the chart or EHR. Another frequent issue is a care plan that still reflects an older goal of care after the resident changed preferences. Facilities also miss cases where the resident or representative was not informed of available options or where the most recent version was not clearly labeled.

Yes. You can add fields for memory care, skilled nursing, hospice coordination, hospital transfer packets, or state-specific forms. Some facilities also add prompts for POLST or MOLST where those orders are used. The structure is flexible enough to fit paper charts, EHR workflows, or hybrid records. Keep the core checks intact so the audit still proves the document is current and actionable.

It forces the reviewer to confirm that emergency response staff can identify code status without delay and that the access path is documented. That reduces the risk of searching through multiple folders or relying on memory during a rapid response. If the directive is stored in the EHR, the template can capture the exact location or navigation path. If copies are kept in multiple care settings, the audit can verify they match.

A general chart audit may look at many parts of the record, while this template focuses specifically on advance directives and whether they match current resident wishes. It is narrower, more actionable, and better suited to recurring compliance checks. Because it includes accessibility, alignment, and corrective action fields, it produces a clear follow-up trail instead of a vague note. That makes it easier to close deficiencies and prove completion.