Healthcare Planning Procedures

HEALTHCARE PLANNING PROCEDURES

Patient Information

Date of Birth:    Gender:

Primary Phone:    Emergency Contact:

Relationship to Patient:    Contact Phone:

Insurance Information

Medical History

Care Planning Preferences

Overall Goals of Care:

Code Status (select applicable):

Do Not Resuscitate / Do Not Attempt CPR (DNR/DNAR)
Full Resuscitation (Attempt CPR as indicated)
Limited Resuscitation (as directed by clinician)

Other Treatment Preferences (select any that apply and provide details):

Mechanical Ventilation — If selected, specify limitations:

Antibiotics — If selected, specify use:

Artificial Nutrition / Hydration — If selected, specify duration or conditions:

Designated Healthcare Proxy / Surrogate

Designated Proxy Name:

Relationship to Patient:

Proxy Phone:

Proxy Address:

Scope of Proxy Authority (check applicable):
Make all medical decisions when patient lacks capacity
Limited authority as specified in attached directive or notes

Procedure for Implementation and Documentation

The clinical team will document this plan in the medical record, incorporate any legally executed advance directive, and communicate applicable elements to all members of the care team. The plan will be followed in emergent and non-emergent settings to the extent permitted by law and clinical judgment. Deviations from this plan will be documented with clinical justification.

Responsible Parties: Primary treating clinician, assigned nurse, care coordinator, and the designated proxy share responsibility for implementing and reviewing the plan. The patient may revoke or amend preferences at any time while having decision-making capacity.

Advance Directive & Attachments

Advance Directive Attached: Yes    No
If attached, location in record or physical location:

HIPAA Authorization and Release of Information

I authorize release of protected health information as necessary to implement this plan to the following persons or entities. This authorization includes clinical, diagnostic, and care planning information necessary to coordinate care.

Scope of Information (check all that apply):
Clinical and treatment information
Billing and insurance information
Other (specify below)

This authorization expires on: . The patient understands that the authorization may be revoked in writing at any time, except to the extent that action has already been taken in reliance on it.

Review and Revision

Last Review Date:    Next Recommended Review:

Acknowledgment and Certification

By signing below, the patient or legally authorized representative certifies that the information supplied is true and complete to the best of their knowledge, that the stated preferences reflect the patient's wishes at the time of signing, and that the patient understands the right to revoke or amend this plan in writing while possessing decision-making capacity. Healthcare providers who act in good faith reliance upon this plan and accompanying documentation are authorized to follow the instructions set forth herein.

The patient acknowledges that medical circumstances may require modification of these preferences in emergent situations and that clinical judgments will be documented if divergence from stated preferences is necessary for patient safety.

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