Date of Service: [Date]

Patient: [Full name, MRN]

Clinician/Author: [Name, credentials]

Setting: [inpatient ward / ICU / ED / outpatient clinic / SNF / home / telehealth]

Reason for ACP Today: [Trigger for discussion: new diagnosis, change in condition, hospitalization, care transition, periodic review, or other]

Participants & Capacity

Participants present:

Patient: [present / not present] (If not present, briefly state why.)
Family/Surrogates: [Name, relationship, role] (List each participant.)
Team members: [Name, role] (Include if present.)

Decision-making capacity: [has capacity / lacks capacity / fluctuating / uncertain] (If limited, note basis: delirium, dementia, sedation, or other.)

Legal decision-maker if patient lacks capacity: [Health care agent / DPOA-HC / default surrogate / no designated agent] — [Name, relationship] (Verification: [documented in chart / patient report / surrogate report / unknown]) (Do not assert legal certainty if no formal designation exists.)

Discussion

Medical Context: [Key diagnoses, recent events, functional trajectory driving this discussion] (If repeat ACP, note what has changed.)

Patient/Surrogate Understanding: [Stated understanding of illness and prognosis; information provided by clinician; confirmation of understanding]

Values & Priorities: [What matters most to patient; unacceptable outcomes to avoid] (Include one or two brief direct quotes only if especially salient.)

Goals of Care: [curative / life-prolonging / function-focused / comfort-focused / time-limited trial / hospice-oriented] (Connect to patient values and clinical context.)

Treatment Preferences:

Code status: Prior: [prior status / unknown] → Current: [Full Code / DNR / DNI / DNR-DNI / Limited Interventions] (Rationale: [brief]) (Order placed: [yes / no / not applicable])
Other interventions discussed: [Summarize preferences for relevant interventions such as ventilation, ICU care, artificial nutrition, dialysis, hospitalization vs treat-in-place, or hospice] (State "not discussed" for topics raised but not addressed.)

Documents & Plan

Documents: Advance Directive: [yes / no / unknown]; Health Care Agent designated: [yes / no / unknown] — [Name if yes]; POLST/MOLST: [present / not present / unknown] (Note any documents completed or updated today and where filed.)

Next Steps: [Immediate actions/orders; who will be informed of preferences and how; where preferences are documented for visibility; when to revisit ACP]

Billing Attestation

(Include only if billing CPT 99497/99498 and face-to-face ACP time exceeds 15 minutes. If patient/surrogate declined ACP, document the decline above and omit this section.)

Advance care planning was offered voluntarily and the [patient / surrogate] agreed to participate. (Required statement; do not leave as placeholder.)

Time: Start [HH:MM], Stop [HH:MM], Total face-to-face ACP time: [minutes] (If ACP occurred during the same encounter as other time-based services, state that ACP time did not overlap.)

Specialties

Advance Care Planning Note

Document Type

Specialties

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