Reminder on physician medical record documentation standards related to Advance Directives:
For medical records of adults, documentation should be included in the medical record on whether or not the individual has executed an advance directive. An advance directive is a written instruction such as a living will or durable power of attorney for health care relating to the provision of health care when the individual is incapacitated.
Physicians are encouraged to initiate discussions with members who do not have an advance directive completed and document the discussion in the medical record. Members are encouraged to provide their physicians with a copy of the fully executed advance directive. This will help to ensure that the member’s wishes are carried out appropriately, should the situation arise.