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Detailed Instructions for Using the ACP Form

The ACP Form contains the most up-to-date information from a patient or family after a provider has spoken to them using the Serious Illness Conversation Guide

If you open the form and it contains responses, another clinician has previously discussed some of the questions.

  • If the previous discussion occurred during this same clinic visit or admission, the "Date" and "Documented by" fields provides that information
  • If the "Date" and "Documented by" fields are empty, you can identify the previous clinician by hovering over "Adv Care Plan" or "Code Status" in the Storyboard

Hover over "Adv Care Plan" or "Code Status"

Input Date, Documented by, and Discussion Participants
 to reflect when you are having the conversation and with whom. Discussion Participants may need to be updated if they have changed from a previous discussion.

Confirm any previous information with the patient, offering to make additions or revisions, rather than asking that question again. For example, "I see that you spoke to Dr. Jones on May 5th and told her that you are hoping to be fee of pain; is that still true?" For all sections except the Prognosis Section Comments, override previous information with new information if the stituation has changed.

Prognosis Section buttons can be updated. If discussing prognosis is not within your scope of practice, please skip this section. Do not override prior documentation in the Prognosis Section Comments section. If you have new information to add to the Prognosis Section Comments, make a new line, input the date (.DATE) and your name (.ME) followed by your new prognosis information.

Updates to Prognosis should include Date, Provider Name, and new prognosis information.


Document your discussion, leaving blank any sections you did not cover during your conversation.

The final steps in the workflow varies, depending on if you are in an inpatient or an ambulatory setting.


Click "Next" to go to the ACP Notes section and click "Create an ACP Note". Once the note opens, click F2 to see the 2 note options. Choose ACP Form Note to pull the SmartForm with responses into the ACP Note. The Goals of Care Note is purely narrative and used for code status changes. Continue clicking F2 to complete the open areas and sign the note. The blue instructions labeled “Vanishing Tip”, will go away when you sign the note and will not appear in your final documentation.

Complete documentation by creating an ACP Note. Clicking F2 lets you choose either "Goals of Care Note" or "ACP Form Note."



Close the ACP Form. Then, in your progress note, type .ADVANCECAREPLANNINGSMTFORM. This will insert the ACP Form into your note.

There are multiple dot phrases that begin with ADVANCECARE.