Advance Care Planning (ACP) Discussion Guide And Visit Documentation Template

Publication Date: January 2, 2018

5-S (Environment)

5-S (Environment)

  1. Scene – Select location for privacy and comfort sensitive to patient’s needs.
  2. Setting – Create friendly, engaging, quiet and confidential environment.
  3. Seating – Make patient, family, staff at ease; seating that is congenial and conducive to interaction.
  4. Scenario – Long-Term Care (LTC) and other settings.
  5. Start with open ended question – No interruption for the first two minutes and allow silence between responses.

C-A-R-E (Engagement)

...C-A-R-E (...

...D CLARIFY Cause: What is the r...

P-L-A-N (Execution)

...P-L-A-N (Execut...

...PLAN Prepare: Document the Advance Care...

ACP Visit Documentation Template

...cumentation TemplateACP Template Sample...