Intent Sheet Version 6

Yes

Original Present • Make copy and return original to patient

Do you have an Advance Directive? *

Stored Here • Look in old chart to see if Advance Directive is present • If not, check with CA to see if AD has arrived • If not, contact HIM x 1670 to check status

______ Initials ______ Initials

Patient/Family Bring In • Document who will bring in Advance Directive and by what date / time Who______________ Date______________ Time______________ • Document intent in space provided below • Enter 'F/S' in AD section of HBOC**and enter treatment order for follow up (if applicable) ______ Initials

No

• Ensure patient has information • Ensure HBOC reflects 'N' in AD section** ______ Initials

Advance Directive Received? AD Received • Place in front of chart in plastic sleeve • Place Advance Directive sticker on front of chart and in progress notes • Ensure 'Y' is entered in AD section of HBOC**

Yes

______ Initials

No

If Not Received • If not found, contact patient / family to inform AD could not be located here • If patient / family does not bring in by required date, document in progress notes • If patient requests AD see procedure to right • Update HBOC to reflect 'N' in AD section** ______ Initials

If Patient Requests Advance Directive • Enter Pastoral Care consult in HBOC AND • Ensure HBOC reflects 'CON' in AD section** ______ Initials • Pastoral Care consult completed ______ PC staff initials

Document intent in space provided below - Ensure patient understands this is not an Advance Directive but, rather, a summary of their intended wishes

Done

Initials

Signature / Title

Date

Time

Notes * If patient is unresponsive, assume patient has AD, conduct necessary search, and document in progress notes ** Refers to AD section of revise patient nursing / medical page

Patient Label

Advance Directive Documentation Forms/Order Sets > Forms > Nursing Forms > AD Intent Form

Patient Label

Advance Directive Documentation Forms/Order Sets > Forms > Nursing Forms > AD Intent Form