Advance Directives - Ccma
- What is the primary purpose of a DNR order?
- To withhold CPR if the patient has cardiac or respiratory arrest. It respects patient autonomy by preventing unwanted resuscitation attempts during life-threatening events.
- Which option best describes the MA role when a patient asks for DNR/DNI advice?
- Refer to the provider; do not provide legal or medical counseling. Medical assistants must defer to qualified professionals to avoid overstepping scope of practice.
- What should you do if family requests DNR but the chart shows full code with no DNR order?
- Notify the provider immediately; do not change code status yourself. Medical assistants cannot alter orders; provider involvement ensures proper protocol adherence.
- Which patient group is MOLST/POLST primarily intended for?
- Patients with serious illness, advanced frailty, or near end of life. These forms target individuals where treatment decisions are imminent to align care with goals.
- Which document is a clinician-signed medical order: advance directive or MOLST?
- MOLST. MOLST forms are executed by clinicians as enforceable orders, unlike patient-driven advance directives.
- What should you document when a patient brings an out-of-facility MOLST/POLST form?
- Presence of form, date, orders listed, and that a copy was scanned. Documentation verifies the form's existence and integration into the patient's record for reference.
- Which document should be honored across care settings as a portable order: MOLST/POLST or living will?
- MOLST/POLST. MOLST/POLST are designed as transferable orders to maintain continuity of care preferences.
- What does "Full Code" mean in code status documentation?
- Attempt CPR and advanced resuscitation measures if arrest occurs. It directs comprehensive efforts to revive the patient, aligning with default life-saving protocols.
- What is required for a DNR to be valid in the medical record in most settings?
- A provider order documented and signed per facility policy. Validity requires a clinician's signature and proper documentation to ensure enforceability in emergencies.
- Which document is typically patient-executed and not a medical order: MOLST or advance directive?
- Advance directive. Advance directives are legal instruments signed by patients to guide future care, not direct medical orders.
- What must you do if you find a DNR form in the chart that lacks required signatures?
- Notify the provider; treat as not valid until properly completed. Unsigned forms lack legal validity, requiring provider intervention to protect patient safety.
- What is the correct action if advance directive documents conflict with a newer MOLST/POLST order?
- Escalate to the provider; follow the most current valid medical order. Provider escalation resolves discrepancies, with the latest order typically governing care.
- What is the correct response if a patient wants to revoke or change an advance directive?
- Notify the provider; document the request and obtain updated documents. Provider notification ensures legal revocation processes are followed with updated records.
- What is a health care proxy (durable power of attorney for health care)?
- A legal appointment of an agent to make health decisions if incapacitated. It designates a surrogate decision-maker to act on the patient's behalf, preserving autonomy.
- What is an advance directive in clinical documentation?
- A legal document stating future medical care wishes if incapacitated. It enables patients to communicate treatment preferences in advance, ensuring autonomy when decision-making capacity is lost.
- What does MOLST (or POLST) document in a portable medical order format?
- Specific, actionable medical orders for serious illness or frailty. It translates patient preferences into binding medical orders that are portable across healthcare settings.
- What is the correct documentation step after verifying a health care proxy in the chart?
- Record agent name and contact info in the designated EHR location. Proper recording facilitates quick access during care decisions, ensuring the proxy can be contacted.
- What does "Comfort measures only" generally indicate on a MOLST/POLST?
- Focus on symptom relief; avoid burdensome life-prolonging interventions. It prioritizes palliative care to enhance quality of life without aggressive treatments.
- What is required to document a code status change (for example, Full Code to DNR)?
- A provider order and updated documentation in the designated code status field. Changes require clinician authorization and clear EHR updates to reflect current status accurately.
- Which source takes priority for immediate code status: a signed provider order or a verbal family request?
- A signed provider order. Signed orders carry legal weight and must guide actions over unverified verbal inputs.
- What is the primary purpose of a DNI order?
- To withhold endotracheal intubation and mechanical ventilation. It honors patient wishes to avoid invasive procedures that prolong life without improving quality.
- What is the key difference between a DNR order and an advance directive?
- DNR is a current medical order; an advance directive is legal guidance. DNR provides immediate, specific instructions as a medical order, while advance directives offer broader legal preferences.
- Which element is essential when scanning an advance directive into the EHR?
- Document type, date, patient identifiers, and correct chart indexing. These details ensure accurate identification, accessibility, and legal compliance in electronic records.
- What is the correct action if a patient states they have an advance directive but none is on file?
- Request a copy and document the statement per policy. This maintains record completeness and adheres to policies for honoring patient wishes without a physical document.
- What is the correct privacy practice when handling advance directives and MOLST forms?
- Treat as PHI; share only with authorized staff involved in care. These documents contain sensitive health information protected under HIPAA regulations.