Advance Care Planning Order Form
Making Advance Planning a Priority
The MAPP Program
Dear Dr. ___________,
At _________________________ (facility name) we are committed to collaborating with our physicians to respect our resident’s wishes for care. While all _________ (facility name) residents have documentation of their preference for or against resuscitation, there are many other trajectories of clinical decline that are not generally addressed in the medical record. Our goal is to elicit care preferences beyond DNR or Full Code orders. Thus, as a Quality Assurance Initiative, the MAPP program team screens every resident for annual mortality risk and notifies the attending physician if the resident is identified at high risk for mortality. We then offer several options to assist physicians elicit the care goals of these residents.
___________________________ (resident name next year) has been identified at high risk for mortality in the.
Please consider the following options to assist in clarifying the care preferences for this resident. Check the appropriate box below and leave in the physician orders section of the chart, FAX to XXX-XXX-XXXX OR call XXX-XXX-XXXX to give a verbal order regarding your wishes for your patient.
- Care preferences for this patient can be found in my progress note dated ______.
- I will be discussing care goals with my patient and their family in an upcoming visit.
- Please refer my patient and their family for Palliative Care Consultation specifically to address care goals and/or symptom management.
- Please refer my patient for Hospice evaluation/admission.
Physician Signature
Date
_____________________________________________ _______________
