Run Family Meeting Documentation Audit — Free

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 critical (required)

Confirm the note identifies whether the patient participated directly or a surrogate/family decision-maker was present.

Yes No N/A

Clinical attendees listed by name and role critical (required)

Attending clinicians should be identifiable by name and role, such as physician, nurse, social worker, chaplain, or case manager.

Yes No N/A

Family members or other participants documented

Confirm the note includes other participants who were present or involved in the discussion.

Yes No N/A

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.

Yes No N/A

Discussion Content

Reason for meeting documented critical (required)

The note should state why the meeting occurred, such as clinical update, prognosis review, treatment options, or goals-of-care clarification.

Yes No N/A

Clinical status or prognosis summarized critical (required)

Confirm the note summarizes the patient’s current condition, prognosis, or key clinical issues discussed.

Yes No N/A

Options, risks, and benefits documented

The note should reflect the major treatment options discussed, including relevant risks, benefits, or burdens.

Yes No N/A

Questions, concerns, or values expressed by family documented

Confirm the note captures family questions, concerns, patient values, or stated priorities that influenced the discussion.

Yes No N/A

Decisions and Plan

Decisions reached clearly documented critical (required)

The note should clearly state any decisions made during the meeting, including treatment direction or code status changes if applicable.

Yes No N/A

Follow-up plan documented with responsible party critical (required)

The note should include next steps, timing, and who is responsible for follow-up actions.

Yes No N/A

Consults, referrals, or orders referenced when applicable

Confirm the note references any ordered consults, referrals, or care plan changes resulting from the meeting.

Yes No N/A

Communication plan to patient and family documented

The note should indicate how the plan will be communicated or reinforced with the patient and family.

Yes No N/A

Documentation Quality and Compliance

Documentation is timely and signed by author critical (required)

The note should be entered promptly and authenticated according to facility policy.

Yes No N/A

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.

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Run: Family Meeting Documentation Audit

Audit Details

Attendees and Roles

Discussion Content

Decisions and Plan

Documentation Quality and Compliance

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