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Inspection Details

Resident identifier and review date recorded

Document the resident name or internal identifier, unit/room, and the date of the advance directive review.

Review trigger identified

Select the reason for this review.

Reviewer name and role documented

Record the staff member completing the review and their role/title.

Resident or legal representative participation documented

Confirm whether the resident, healthcare proxy, or legal representative participated in the review when appropriate.

Yes No N/A

Advance Directive Documents Current and Complete

Code status is documented and current critical (required)

Verify the resident's current code status is clearly documented and reflects the latest order or directive.

Yes No N/A

Healthcare proxy or durable power of attorney for health care is present and current critical (required)

Confirm the designated healthcare proxy or health care agent document is present, legible, and not expired or superseded.

Yes No N/A

Living will or equivalent advance directive is present and current critical (required)

Confirm the resident's living will or equivalent directive is available in the record and reflects current wishes.

Yes No N/A

DNR or other resuscitation order is present when applicable critical (required)

Verify that any DNR, DNAR, or equivalent resuscitation order is present when applicable and matches the resident's current code status.

Yes No N/A

Documents are signed, dated, and authorized as required critical (required)

Check that required signatures, dates, witness or notary requirements, and provider authorizations are complete for each applicable document.

Yes No N/A

Most recent version is clearly identified in the record

Confirm the chart contains the latest version and any prior superseded forms are clearly marked or archived per policy.

Yes No N/A

Resident Wishes and Care Plan Alignment

Documented wishes match current resident preferences critical (required)

Verify the advance directive content aligns with the resident's current stated wishes or the legally authorized representative's instructions.

Yes No N/A

Any change in preferences has been escalated for update

Confirm any discrepancy, change in condition, or new preference has been communicated to the care team and routed for order or document update.

Yes No N/A

Care plan reflects current code status and goals of care critical (required)

Check that the resident care plan, treatment preferences, and emergency response instructions align with the current advance directive documentation.

Yes No N/A

Resident or representative informed of available options and implications

Confirm the resident or representative was offered review of available advance care planning options and informed of the implications of the current orders.

Yes No N/A

Accessibility and Availability to Care Team

Advance directive documents are readily accessible in the chart or EHR critical (required)

Verify the current documents can be located quickly by nursing and clinical staff in the paper chart or electronic health record.

Yes No N/A

Copies are available to relevant care settings critical (required)

Confirm copies are available to the nursing unit, on-call coverage, transfer packet, and other relevant care settings per facility policy.

Yes No N/A

Emergency response staff can identify code status without delay critical (required)

Verify code status and resuscitation preferences are visible or retrievable in a way that supports timely emergency response.

Yes No N/A

Document location and access method recorded

Record where the current documents are stored and how staff access them during routine care and emergencies.

Deficiencies, Corrective Actions, and Sign-Off

Deficiencies identified

Select all deficiencies observed during the review.

Note (optional)

Corrective action documented for each deficiency critical (required)

Confirm a corrective action, responsible person, and target completion date are documented for each non-conformance.

Yes No N/A

Follow-up review date set

Enter the date and time for follow-up verification of any open corrective actions.

Note (optional)

Inspector signature critical (required)

Inspector attestation that the review was completed accurately.

Supervisor or clinical leader review completed

Confirm supervisory review when required by facility policy or when critical deficiencies are identified.

Yes No N/A

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Run: Advance Directive Review and Update

Inspection Details

Advance Directive Documents Current and Complete

Resident Wishes and Care Plan Alignment

Accessibility and Availability to Care Team

Deficiencies, Corrective Actions, and Sign-Off

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