ACP Status Collection

Projects
Active?:	planned
Program:	CC and Med
Requestor:	Dr. Roberts
Collection start:	2026-06-??
Collection end:

This article is about collecting the "ACP Status" (Advanced Care Planning) temp entry. See ACP Status Collection over time for related collections.

Purpose

We collect ACP status as a quality indicator that reflects documentation (e.g. completed ACP form or Admitting Orders) and discussion of goals of care for all patients admitted to ICU or medicine.

Collection Instructions

• For each new record, use the last documented ACP status in the chart prior to admission date, a date and time is NOT required
• on admission, collect the first ACP status documented by a physician only
• At discharge, collect the last ACP status documented by a physician only

Time entries in this project

• The ACP form does not have a field for time entry, so if there is documentation in the orders or notes with a time entry, use the earliest related date and time documented elsewhere in the chart.
• If a time is not available, use the best estimate for the time. If there is no estimate at all, use noon, or the closest to noon that the Data Integrity Checks will allow.

Level of documentation required

• If status is documented as "presumed ACP R", enter "not documented".

but maybe we need to fine-tune the wording Dan do you agree with this? Lisa Kaita 16:33, 24 June 2025 (CDT)

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If the ACP form does not have a signature, but an ACP status is checked off, should this be entered as not documented? Lisa Kaita 16:33, 24 June 2025 (CDT)

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"True ACP" vs terminal comfort care

• For the #Purpose of this project, we are not considering scenarios where a decision is made to provide terminal comfort care. Collect/code those as if they had not been documented.

Example:

patient deteriorates and the ACP status is established as ACP-C, this could be on admission or anytime after admission. Ex. On day one an ACP R is established and on day 20 they deteriorate and are deemed ACP C, disregard this and do not change the original ACP R status. Ex. an ACP status has not yet been established, patient deteriorates and is deemed ACP C, disregard this and enter the first ACP status as not documented patient is in ICU and they withdraw care

If a patient in this situation continues to live for days, should the ACP status be changed at some point? and if so what timeframe should we use?Lisa Kaita 16:33, 24 June 2025 (CDT)

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Sources

• ACP PTA
  • ACP forms from previous hospitalizations, PCH, health directives can be used to determine the ACP status prior to admission. If the last ACP status prior to admission cannot be readily found within the current chart, enter not documented.
• ACP first
  • ACP form, orders, notes, use ACP forms made during same hospitalization (e.g. ACP status documented by ER, or ward or on prior ICU/ward for transferred patients)
  • SBGH EPR- go to EPR orders. Under "transfers and care directives" there should be an order that states, "advanced care planning goals of care" with the ACP status listed (this also displays in the top of the EPR individual patient demographic information). If you double click on the order, the ACP electronic form displays (it is exactly the same as the paper form which was previously used). When the physician writes the order, the form automatically is populated with the doctor name and the ACP status also. However, if there are special conditions or comments, the doctor may fill out parts of the form itself separately from the displayed order.
• ACP Last
  • ACP form, order, notes use ACP forms made during same hospitalization (e.g. ACP status documented by ER, or ward or on prior ICU/ward for transferred patients)
  • SBGH EPR as per above instruction

Data Entry Instructions

For every new record, an entry of "not entered" will be automatically generated.

Update that line to one of the following:

• Project: ACP PTA
  • Items:
    • not yet entered (automatic entry)
    • ACP-C
    • ACP-M
    • ACP-R
    • not documented
  • Date/Time, Checkbox, Integer, Real: not used

does the ACP Status PTA need to be documented by a physician or can it be documented by another discipline? Lisa Kaita 16:33, 24 June 2025 (CDT) I don't think so, since it would be hard to be sure if an outside documenter is a physician. Also, AFAIK they don't need to be a physician for this to count. I wonder if a more important factor would be whether it is clearly identifiable as an official status, but I don't know what that would mean in terms of chart review. Ttenbergen 17:17, 24 June 2025 (CDT) what does AFAIK mean? Lisa Kaita 18:47, 24 June 2025 (CDT) AFAIK means "As far as I know" Ttenbergen 12:21, 25 June 2025 (CDT) I asked this question because Dan said he only wants an ACP status documented by the a physician for this project, I think that for the most part the ACP PTA will be not documented Lisa Kaita 15:15, 25 June 2025 (CDT)

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• Project: ACP first
  • Items:
    • not yet entered (automatic entry)
    • ACP-C
    • ACP-M
    • ACP-R
    • not documented
• Date/Time, Checkbox: using instructions in #Date/Time in this project, enter the dttm of the status decision
  • if ACP status is established during this hospitalization, but by a different service/ward prior to the medicine/ICU admission, use the first service Admit DtTm

I had understood that DR wanted to know if the doctors on the current service are processing this. That might be a misunderstanding, though. DR if a patient is admitted to our service from another service or ward (icu to medicine, ER to medicine/ICU, surgical ward to ICU/medicine) and has an ACP already established by the previous service, can we use this as the first documented ACP? or do you want to know when the new service establishes an ACP status?

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• • • consider #"True ACP" vs terminal comfort care

• • Integer, Real, Comment: not used

• Project: ACP last
  • Items:
    • not yet entered (automatic entry)
    • ACP-C
    • ACP-M
    • ACP-R
    • not documented
  • Date/Time: using instructions in #Date/Time in this project, dttm of the status decision
  • Checkbox: check if "no dttm" for "same" below
  • which item/Dttm to code:
    • if the ACP last status is the same as the ACP first status, enter the same ACP status as the first, and check the checkbox for "no dttm" as it is not applicable
    • if the ACP last status is different than ACP first status, enter the dttm of the last documented change in ACP Status and the dttm as per #Date/Time in this project
    • consider #"True ACP" vs terminal comfort care

• Comment (optional): If there are multiple ACP status changes/family discussions that are affecting the LOS or seem unusual, leave this as a comment in the "Q" column, NOT the Notes field
  • Integer, Real: not used

Questions?

WRHA/SH guidelines / forms

• Example of WRHA ACP FORM

Data Integrity Checks (automatic list)

none found

Cross Checks

• Query s tmp ACP

Data use / Reporting and Analysis

Reporting and Analysis Files

• the file for the analysis and report can be found in Template:S:\MED\CCMED<to be determined>

Log

• 2025-06-24 TT split this page off from ACP Status Collection for LAU and reverted that one when it became apparent that it will be substantially different, and edited the S_tmp table
• 2025-06-16 LK, TT, DR met and discussed; LK updated ACP Status Collection for LAU page