When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 47 requires documentation of a patient’s advance care plan or surrogate decision maker in the medical record or, documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
We do not need to see full text of the advance care plan but we should see a notation in the record that the care plan was developed or discussed. If a surrogate decision maker is identified, we should be able to view the name and relationship of the surrogate decision maker.
If claiming that the patient did not wish to provide an advance care plan or name a surrogate decision maker, indicate the reason for the patient’s decline.
This documentation may be found in the medical record. The relevant document should be made available to the auditor for the patient requested.