Advance Directive Review and Update

This template covers the periodic review of a resident’s advance directive, code status, and related documentation in a long-term care or skilled nursing setting. It is meant to confirm that the chart, care plan, and posted or accessible orders match the resident’s current wishes. It also helps staff note missing signatures, expired forms, or changes that need provider follow-up. The template is focused on review and documentation, not on completing legal forms from scratch.

Use it on a recurring cadence that matches your facility policy, such as admission, quarterly review, annual care plan review, and after any major change in condition or goals of care. Many facilities also run it when a resident is transferred, returns from the hospital, or updates their preferences. The key is to make the recurrence explicit so the review does not depend on memory. If your policy differs by unit or payer, customize the recurrence to match that workflow.

A nurse, social worker, case manager, or other designated DRI usually completes the review, depending on facility policy. The person running the checklist should be able to verify the chart, confirm the resident or surrogate conversation, and route changes to the appropriate provider. If the review requires a physician or advanced practice provider signature, the checklist should capture that as a follow-up task. The assignment should reflect your local process rather than forcing a fixed role.

It is a clinical documentation aid, not a legal advance directive form. The template helps staff verify that the resident’s current documents are present, readable, and aligned with the charted code status. If a resident needs a new directive, the checklist should route that work to the proper legal or clinical process. Facilities should still follow state-specific rules for witnessing, signatures, and storage.

A common failure is having an old code status in the chart that no longer matches the resident’s current wishes. Another is documenting a conversation without confirming whether the signed form was updated or filed in the correct location. Facilities also miss follow-up when a resident changes condition and the review is not repeated. This template reduces those gaps by making each verification step explicit and assignable.

Yes. You can tailor the checklist items for memory care, post-acute rehab, hospice-aligned residents, or long-stay residents with different review triggers. You can also add unit-specific fields for surrogate contact, POLST/MOLST status, or provider notification. Keep the checklist items atomic so each one can be answered yes, no, or not applicable. That makes the template easier to audit and easier to hand off between shifts.

This template works well alongside admission packets, care plan review, chart audits, and provider notification workflows. It can be linked to tasks for scanning documents, updating the EHR, notifying the attending provider, or requesting a new signature. If your system supports it, connect the checklist to resident records so the reviewer can open the chart and attach evidence in one place. The goal is to turn a compliance review into a traceable task sequence, not a separate paper process.

Do not use it as a substitute for emergency decision-making, legal counseling, or a state-specific advance directive form. It also should not be used for residents whose preferences are actively changing without a provider or surrogate conversation documented elsewhere. If your facility handles only short-stay rehab or has a different code-status policy, adjust the scope and cadence before rollout. The template is best when the review is routine, repeatable, and tied to a clear documentation standard.