The federal Patient Self-Determination Act addresses the right of health care users to indicate, in advance, how they would like to be treated by health care professionals and institutions if they became incapacitated. The common term for this document is an Advance Directive and it is mandated by the federal government.
New Jerseyis set apart from many states in that there are two documents that can be used as an Advanced Directive. The New Jersey Appointment of a Health Care Representative allows the patient to name someone to make decisions about medical care while the New Jersey Instruction Directive allows the patient to provide specific instruction and direction regarding his or her own medical care. Either of these or documentation of discussion regarding Advance Directive must be included as part of the patient’s permanent medical record, per the federal Patient Self-Determination Act.
For more information on advance directives as part of medical record documentation standards, please contact the Quality Department at 1-800-682-9094, extension 89222.