ACP Status Collection
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| 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 discussion of goals of care for all patients admitted to ICU or medicine. The primary intent is the collection of the actual status, not the quality of the documentation. We may do a different collection project at a later time to address the quality of documentation.
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
- Code based on whether there is evidence in the chart that a deliberate conversation about goals of care happened.
- If status is documented as "presumed ACP R" and there is no evidence that a conversation happened, enter "not documented".
- If the form is not signed, but there is other charting that indicates a physician had a conversation with the patient, code as per the form, ie we don't care that the form was not signed but that a conversation happened.
"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: |
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- If the patient lives longer than initially anticipated, then code continued status as usual. That is, if there is evidence of a deliberate conversation about goals of care, this can be coded. There is no specific timeline of how long the patient has to live for this to apply.
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Sources
- ACP Prior to admission (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. The PTA ACP does not need to be established or signed by a physician.
- 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
- Items:
- Project: ACP first
- Items:
- not yet entered (automatic entry)
- ACP-C
- ACP-M
- ACP-R
- not documented
- Items:
- 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
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Task
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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
- Items:
- 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
Data Integrity Checks (automatic list)
none found
Cross Checks
Data use / Reporting and Analysis
Reporting and Analysis Files
- the file for the analysis and report can be found in S:\MED\Med_CCMED\S:\MED\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