ATTENTION: IF YOU USE THIS INSTRUMENT FOR RESEARCH PLEASE CREDIT SUSAN HICKMAN, PhD

Patient ID Code: ______

Oregon NURSING HOME CHART REVIEW Short Version

1. Today’s date ______

2. What is the reason for this chart review?

□ regular review

□ change in status (indicate type of change):

□ hospice admission

□ discharge to home

□ discharge to hospital

□ other ______

NURSING FACILITY PREFERENCES, ORDERS, & LIFE-SUSTAINING TREATMENTS

3. PREFERENCES: Have any discussions occurred at the nursing home regarding treatment preferences? □ yes □ no

If yes, describe:

Date of Discussion / Staff involved? Identify. / Patient/family involved? Identify. / Was surrogate authorized? If so, describe role.

a. Where is this documented? ______

b. Who documented the discussion? ______

c. Length of discussion

□ 0-15 min.□ 15-30 min.□ 30-45 min□ no time listed

d. What was discussed? Please describe treatment preferences or plans.

______

4.Who is making decisions at this point in time?

Patient

Healthcare Agent

Legal Guardian

Designated Decision-maker

Next of Kin

Other:______

5.What, if any, advance directive forms are present in the chart? (Check all that apply)

Advance directive/living will (circle type used and indicate date of document)

  • LaCrosse Respecting Choices POAHC_____/_____/______Date
  • Addendum to POAHC_____/_____/______Date
  • Statement of Treatment Preference form_____/_____/______Date
  • Wisconsin Statutory POAHC_____/_____/______Date
  • Wisconsin Declaration to Physicians OR

other Living Will_____/_____/______Date

Designated Decision-maker (named by resident)_____/_____/______Date

Legal Guardian_____/_____/______Date

Other (describe) ______/_____/______Date

No form present

6. Were any documents created since admission to nursing home? □ yes□ no

a.If yes, what type of document was completed? ______

b.Date? ______

c.Certification of provider signing document______

7. Document alltreatment preferences in the table below. (See advance directive).

IF I AM CLOSE TO DEATH:
I want feeding tubes/artificial nutrition and hydration.
I want tube feedings only as my physician recommends
I do not want feeding tubes/artificial nutrition and hydration
No preference indicated
I want any other life support that may apply
I want life support only as my physician recommends
I want NO life support
No preference indicated / IF I AM PERMANENTLY UNCONSCIOUS/PERISTENT VEGETATIVE STATE:
I want to receive tube feeding
I want tube feeding only as my physician recommends
I do not want tube feeding
No preference indicated
I want any other life support that may apply
I want life support only as my physician recommends.
I want NO life support
No preference indicated

KIDNEY DIALYSIS

 I do want kidney dialysis
I do not want kidney dialysis
No preference indicated /

VENTILATOR SUPPORT

 I do want ventilator support
I do not want ventilator support
No preference indicated.
RESUSCITATION (preferences, not orders)
 I do want cardiac resuscitation
I do not want cardiac resuscitation
I want CPR under certain circumstances as MD recommends
No preference indicated / LOSS OF ABILITY TO RELATE TO SELF, OTHERS AND ENVIRONMENT
I do not want CPR
I do not want antibiotics
I do not want a feeding tube, artificial hydration and nutrition
No preference indicated

ANTIBIOTICS

 I do want antibiotics
I do not want antibiotics
No preference indicated /

TRANSFUSION

 I do want transfusion
I do not want transfusion
No preference indicated

PAIN AND SYMPTOM CONTROL IF EFFORTS TO PROLONG LIFE ARE STOPPED

I want to be kept comfortable even if it risks my dying sooner
No preference indicated /

HOSPITALIZATION

 I do want ______
 I do not want ______
 No preference indicated
Agent authority to admit me to a nursing home or community-based residential facility for the purpose of long-term care:
 Yes
No / Agent authority to order the withholding or withdrawal of feeding tube and IV hydration:
 Yes
No
OTHER PREFERENCES

8. Are there any medical order forms or orders for life-sustaining treatments in the chart?

A. If yes, what type of orders?

□ Wisconsin DNR order form/bracelet_____/_____/______Date

□ POLST (Please document orders found on POLST below)

a. Is document signed? □ yes□ no

b. Is document dated?□ yes□ no

If yes, date signed:_____/_____/______Date

c. Is there a resident/surrogate signature on back? □ yes□ no

d. What parts of document have been completed?

□ A □ B□ C□ D□ E

□ Standard order form?□ yes□ no

If yes, describe: ______

□ Other order form? □ yes□ no

If yes, describe: ______

9.MEDICAL ORDERS RE LIFE-SUSTAINING TREATMENT: Document all medical orders written in the chart in the table below.

TREATMENT CATEGORY

/

CHECK

BOX

/

WRITTEN ORDERS

/

DATE OF ORDER

Resuscitation / DNR/DNAR
Full Code
Other Orders

10. POLST ORDERS RE LIFE-SUSTAINING TREATMENT: Document all POLSTorders in the table below.

TREATMENT CATEGORY

/

CHECK

BOX

/

WRITTEN ORDERS

/

DATE OF ORDER

A. Resuscitation / DNR/DNAR
Full Code
B. Medical Interventions / Comfort measures only….allow a natural death to occur
Do not hospitalize
Limited/advanced treatments
Full treatment
C. Antibiotics / No antibiotics
No IM/IV antibiotics
Antibiotics
D. Artificial Nutrition and Hydration / No artificial nutrition or hydration
Limited trial for _____ days
Artificial nutrition and hydration

11. TREATMENTS: Document life-sustaining treatments below.

TREATMENT PROVIDED / Dates of occurrences / Treatments Provided &
Other Relevant Information
Resuscitation / 1)______
2)______
EMS visit with/without transport
(indicate treatments provided by EMS) / 1) ______
2) ______
3) ______
4) ______/ 1) ______
2) ______
3) ______
4) ______
Emergency Department Visit without hospitalization / 1) ______
2) ______
3) ______
4) ______/ 1) ______
2) ______
3) ______
4) ______
Hospitalization: / 1) ______
2) ______
Surgery: / 1) ______
2) ______
Transfusion: / 1) ______
2) ______
3) ______
4) ______
Intubation: / 1) ______
2) ______
3) ______
4) ______
Dialysis: / 1) ______
2) ______
3) ______
4) ______
Antibiotics: / 1) ______
2) ______
3) ______
4) ______
Feeding Tubes: / 1) ______
2) ______
3) ______
4) ______
IV Fluids: / 1) ______
2) ______
3) ______
4) ______
Chemotherapy / 1) ______
2) ______
3) ______
4) ______
Ventilator/Respirator / 1) ______
2) ______
3) ______
4) ______

Nursing Home Follow-up

12.While at nursing home has there been any change regarding life-sustaining treatment orders? □ yes □ no

a. If yes, who initiated the conversation?

b. Who was involved in the discussion?

c. Who made the decisions?

d. How many days after admission did the orders change?

e. Please describe change in treatment orders.

______

NURSING HOME CHART REVIEW FORM: page 1

Created on 10/15/2018