.-------
I 
\D epartment  of Health  and Humm  Services
OFFICE  OF 
INSPECTOR  GENERAL 
PATlENT  ADVANCE  DIRECTIVES: 
EARLY  IMPLEMENTATION  EXPERIENCE 
o~  06-91-o1130 
AUGUST 1993 
L 
.    EXECUTIVE  SUMMARY 
PURPOSE 
To determine  the extent of institutional compliance  with the Omnibus Budget 
Reconciliation  Act of 1990 advance directive provisions one year after enactment  and 
determine  the patients  understanding  of their rights as well as the information  provided  to 
them under the law. 
BACKGROUND 
On November  5,  1990 the Congress enacted advance directive provisions  as part of the 
OBRA-90.  These provisions,  however,  became effective December  1, 1991.  The intent 
of this law is to provide  an opportunity  for adult patients to express their desires  about 
medical treatment  in a variety of settings.  An additional intent is to educate the entire 
population  on advance  directives  such as living wills and the durable power of attorney for 
health care.  This law creates no new rights for patients,  it simply requires  health care 
providers  to inform  individuals of any rights they have under State law, regarding  patient 
self-determination. 
It is important  to evaluate  early implementation  efforts due to the laws potential  effect on 
all Americans  health  care decisions.  For this evaluation,  a facility level review  was 
undertaken  at 72 facilities,  in six States in a total of 12 counties.  We interviewed  staff 
responsible  for implementing  the requirements  of the law at each facility,  obtained 
required  written  materials  and reviewed necessary documentation.  Whhin  these facilities, 
1553 charts  were reviewed  and 348 patients or family members were contacted  for phone 
interviews. 
FINDINGS 
MOST  OF THE SAMPLE FACILITIES ARE COMPLYING WITH THE GENERAL 
LEGISLATIVE  REQUIWMENTS. 
THE LACK  OF CLEAR AND CONSISTENT DOCEMENTATION  IN PATIENTS 
CHARTS INCREASES  THE POSSIBILITY THAT THEIR TREATMENT  WISHES 
MAY NOT BE FOLLOWED. 
	 Many  Sample  Facilities  had Missing Documentadon  Regarding  Whether or Not the 
Patient hud an Advance  Directive. 
	 Performance  In  Clearly and Consistency  Documenting  l%e Existence  of an 
Advance  Directive  In lhe  Chart Needs Improvement. 
	 Only 60 Percent  of the Pments With Advance Directives  had Copies of the 
Directive  in Xheir Medical  Chart. 
i 
  TWENTY-ONE  PERCENT OF THE PATIENTS IN HOSPITALS,  NURSING 
FACILITIES  AND HOME HEALTH AGENCIES HAVE ADVANCE DIRECTIVES. 
TWO-THIRDS  OF THE INDIVIDUALS INTERVIEWED HAD SOME 
UNDERSTANDING  OF ADVANCE DIRECTWES. 
  We Found No Evidence  of Patients Being Pressured To Have Advance  Directives. 
	 Only 32 Percent of the Facilities Provided Additional  Information In Materials  To 
Promo~e Patient  Understanding of and Comfort Wth  Advance Directives. 
	 Receiving  Information  on Advance Directives Appeared  To Have Some Impact  On 
Patient Interest  in Obtaining A Directive. 
RECOMMENDATIONS 
HCFA should  develop and issue specific regulatory guidelines clarifying acceptable 
documentation  methods to assist providers in meeting the requirements of the Federal 
Statute. 
HCFA should encourage  the Joint  Co-ion  for Accre~~tion  of Hc@h 
Organizations  (JCAHO) to examine if the chart for =ch  patient documents whether 
or not the patient  has an advance directhe,  in addhion to the existiig  JCAHO review 
item for advance  d-ives. 
HCFA,  along  with other appropriate Health and Human Service departmental 
offices,  should  provide leadership to develop a coordinated plan for educating the 
general  public on advance directives. 
AGENCY  COMMENTS 
We solicited  and received  comments from the Health Care Financing Administration 
(HCFA)  on our draft  report. 
The HCFA  did not concur  with our recommendation regarding additional  documentation 
guidelines  in the regulations,  believing that such changes would be overly prescriptive. 
However,  because  technical  questions still remain for providers  regardiig  compliance  with 
the law we continue  to believe that additional guidance would be helpful to providers. 
This guidance  need not be overly prescriptive. 
The HCFA  generally  concurred  with our recommendation concerning the JCAHO review 
of medical  record  documentation  but suggested that JCAHOS current process,  which 
determines  if a copy of the advance directive is present in a sample of records,  addresses 
our concerns.  As a result of this comment,  we refined our second recommendation  to 
ii  TABLE  OF  CONTENTS

. .  i 
EXECU~S~Yco..  . . . . . . . . . . . . . . . . . . . . . . . . . 
. . . . .  11  
INTRODUCflON  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
A 
FIND..I.N...G...S.............................. 
. . . . . . . .U 
FAC~Ty  CO~H~CE  WITH LEGISM~E  REQ~S  . . . . . . .  6
7 
I 
CIWRrDoC~AmoN.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
.  11 
pA~~S-~V~CED~C~~.  . . . . . . . . . . . . . . . . . . . . 
12 
~~T~~GOF~V~CED~C~.  . . . . . . . . . . . . . . . . . 
. ..16 
~CO~A~ONS...........  . . . . . . . . . . . . . . . . . . . . . . . 
..18 
AGENCYCO~S~OIG~~NSE  . . . . . . . . . . . . . . . . . . . . 
. . . . . . 21 
ENDNO~  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
Appendices 
. . . . . .  A-1 
ARe~ssion  Results  ..,....  . . . . . . . . . . . . . . . . . . . . . . . . . 
. .B-l 
B:  Weightd  adUnweightdCM  DataRePofiedhText  . . . . . . . . . . . . . . 
. . . . . . . .C-l
C:  Agency Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
    INTRODUCTION 
PURPOSE 
To determine  the extent of institutional compliance with the Omnibus Budget 
Reconciliation  Act of 1990 advance directive provisions one year after enactment  and 
determine  the patients  understanding  of their rights as well as the information provided  to 
them under the law. 
BACKGROUND 
On November  5,  1990 the Congress enacted advance directives provisions  as part of 
OBIL4 19901.  The intent of this portion of the law is to provide an opportunity  for adult 
patients to express their desires about medical treatment  in a variety of settingsz.  An 
additional  intent is to educate the entire population on advance directives  such as living 
wills and the duxable power of attorney for health care.  These provisions do not create 
any new rights for patients.  The provisions simply require health care providers  to inform 
individuals of any rights they now have under State law, regarding patient  self-
determination. 
Senators Danforth  and Moynihan  introduced the provisions as the Patient Self 
Determination  Act in October of 1989, to afford individuals the opportunity  to participate 
in medical  decisions affecting the condition and length of their lives4.  Such an Act W= 
needed to offset an imbalance  in the relationship between health care consumers  and 
providers.  Senator Danforth perceived  that the caring component was beiig  left out of 
medicine and patient  rights were being trampled uponb. 
Because of the potential  impact of these provisions on all Americans,  it was important to 
determine  if the spirit and letter of this law were being met.  A facility level miew  of the 
requirements  was necessary  to detenrd.ne if the provisions wem being implemented 
appropriately.  It was also crucial to determine if patients were being educated and 
allowed to participate  in the health care decision process,  or if additional paperwork  had 
simply been added to the administrative  process. 
The  Provisions 
The advance  directive  provisions  are contained in the Omnibus Budget Reconciliation  Act 
of 1990.  This section of the law became effective December  1, 1991, approximately  one 
year after enactment,  in all f~y  States.  Dutig  the interim year, health care providers 
participating  in the Me&aid/Medicare  programs were to develop both written policies and 
procedures  and patient  materials addressing dtives  under State law.  Participating 
health care providers  covered by these provisions include, but are not limited to, 
1  hospitals,  nursing  homes and home health care agencies.  The materials  develop~  ~  to 
be provided  to all adults upon admission to a facility or in advance of beginning care. 
Policies  and procedures,  as well as materials provided,  must ensure compliance  with State 
legislation  and/or  court opinions addressing patient directives.  A description  of Snte  law 
must be included  in information  provided  to all adult patients.  Finally,  the patients 
record  must state whether he/she  repons  having executed an advance directive. 
While the advance  directive  provisions  require health care providers  to make this 
information  available  to all adult patients,  certain activities are not required.  The 
provisions  do not require  patients to complete any form of advance directive.  In fact, the 
provisions  expressly  forbid requiring  an advance directive as a requisite for treatment.  In 
addition,  the provisions  do not override  any State law allowing a provider  to object to the 
implementation  of an advance directive  on the basis of conscience.  However,  in such a 
case policies  on this topic should be included in the information provided  upon admission. 
Evolution  of the Advance Directive Provisions 
The advance  directive  provisions evolved both from case law and medico/legal 
considerations.  The final legal decision drawing attention to the need to consider patients 
wishes in health m  decision making was provided in the Supreme  Court ruling in the 
Cruzan  case*.  This case recognized  a patients right to accept or refuse treatment  and 
endorsed  the withbwal  of life support and the withholding of medical treatment  when a 
patients  wishes were known91.0 This ruling helped focus the need to inform patients of
their  rights to state treatment  preferences  regarding life and death matters before 
undergoing  medical  treatment. 
The evolution  of me&co/legal  considerations  over the past ftieen  years also encouraged 
greater  patient  involvement  in their medical care.  These considerations  took three forms: 
1.	 Do not resuscitate  order (DNR), a written order documented  in the patients 
medical  chart to allow patients or family members  to choose to forego 
further  medkxd intervention  in case of an event such as a cardiac  arrest. 
2.	 LNing  will, a document containing written instmctions  pertaining  to an 
individuals  treatment. 
3.	 Durable  power of attorney for health care,  empowers  an individual to 
appoint  an agent or surrogate to decide for them should they become 
incompetent  or unconscious. 
Due to the patients  lack of knowledge about these devices,  communication  between the 
patient  and physician had not increased.  In addition, despite the frequent  use of DNR 
orders,  they often were not discussed with the patient or even the family.  Studies found 
patients  were only asked their preference  for life prolonging  treatment  between  14 and 22 
percent  of the time*1*12s1w3h,ile family members were asked 33 to 86 percent  of the 
time14*slb.Further  studies indicated the agreement between a potential  proxy and 
the patient  on preferences  for life sustaining treatments ranged between 53 and 90 percent 
2  for a family  member17118a,nd between 38 and 89 percent for the patients 
physician1920.Thus,  the literature  indicates the wishes of the patient were frequently 
not considered  before placing an order to forgo resuscitation.  This reinforced  the n=d  for 
the advance  directive  provisions,  which include patient education  about advance directives 
as an important  component. 
Public and Institutional Response to Advance Directives. 
Research  on patients  interests in advanced care directives  supports the need for the 
advance  directive  provisions.  Studies have found between 89 and 9321percent  of 
individuals  surveyed  desire at least one form of advance directive.  However,  two surveys 
indicate  only  1422to  18D percent of individuals have either discussed their desires with 
their physicians  or put them in writing, 
In the realm of hospital policies on advance directives,  a 1988 study of randomly  selected 
hospitals  noted that 67 percent of the nxpondents  reported having a formal policy 
regarding  advance dmtives  24.  However,  of these hospitals, only 63X percent  reported 
a policy  r&@ring  the patient to notify the physician if they had an advance directive. 
Oniy four percent  of the hospitals had a policy of asking all patients whether they had 
ever completed  an advance directive*. 
Concerns Regarding  the Use of Advance Directives.  . 
One concern  addressed  in the literature  is the possibility that the advance directive 
provisions  will have little impact.  A study of New York States legislation  requiring a 
patient  discussion  before issuing DNR orders found no signifkant  change in the number of 
decisions  being made by patients.  Both before and after the legislation,  80% of cases 
involving  DNR orders  were based on decisions made by family members27. 
Another  concern  relating  to the impact of the advance dmtive  provisions  is whether 
patients  will fully understand  the information contained in materials provided,  as well as 
the importance  of the information.  Studies show many existing consent forms require 
reading  skills at the advanced college leve12aand even well-educated  individuals often 
fmd it dilllcult  to understand  terms explained in health care plans to which they 
subscribe29. Concern  also exists that patients may view the information  as just  another 
form and choose not to read i~.  Another risk is that patients may be incorrectly 
informed  of their  rights due to discrepancies between State statutes and legal fmdings3]. 
Additional  concerns  surround the issue of patients making involuntmy  or unreasoned 
decisions  due to the initiation of the informational process upon admission,  frequently  a 
time of turmoi332. Finally,  concern is expressed that facilities will encourage 
disadvantaged  patients  to sign a dtitive  for financial masons,  to limit costs of potential 
extended  titmen?3Y. 
3
 These  concerns  demonstrate  a need to determine  both the administrative  compliance  level, 
as well as compliance  related to the level of patient understanding  of advance directives. 
Researchers  believe  relying solely on a simple patient chart audit to determine  compliance 
with the requirements  of the provisions  could be misleading.  Such reviews  do not 
measure  patients  understanding  of their rights or the lack of a requirement  to have a 
directive  to obtain  medical treatment3sJb. 
METHODOLOGY 
This inspection  reviewed  both institutional compliance with the requirements  of the 
advance  directive  provisions,  and patient understanding of the information  presented  to 
him/her  at time of admission or commencement  of services.  Institutional  compliance  was 
divided  into two components,  administrative  compliance and chart documentation.  Since 
the advance  directive  provisions were Federal  in nature and applied to all 
Medicaid/Medicare  facilities,  all States and all hospitals,  nursing facilities  and home health 
agencies  were  initially  included in our sample.  Individuals who received  care within each 
of these settings  were also interviewed to ascertain their understanding  of the advance care 
directive  information  they received. 
While the content  of State laws was not reviewed in deptl?,  consideration  was given to 
the type of advance  directives  allowed in the sample State#a.  Legislation  in States 
generally  allowed  for the following advance directive possibilities: 
Living  Wills only (9 States)

;:  Durable  Power of Attorney  for Health Care only (6 States)

3.  Living  Will and Durable Power of Attorney for Health  Care (33 States)

A four stage,  stmtifled  random sample was utilized in this study.  The initial stratifkation

was based on the type of advance directive(s)  legislation present  in the State.  Two States

were randomly  selected from each group.  The six sample States were,  Arizona,  Florida, 
Maryland,  Massachusetts,  Michigan and Washington.  After sample States were selected, 
two counties/county  units were randomly  selected fmm each State with probability 
proportionate  to size.  Size was defined as the total number of Medicam/Nledicaid 
participating  hospitals,  nursing facilities and home health agencies in the county unit. 
County unit was deftned as two or more contiguous counties in which one or more has 
fewer than the required  number  (two), of at least one type of organization  included  in the 
sample.  Within  these county units, two of each type of provider  were randomly  selected 
and included  in the sample.  Within each facility,  25 charts were randomly  selected for 
review  from  all the admissions  for the period,  March  1 to April 30,  1992.  For the 
facilities  with fewer  than 25 admissions,  all admissions during the sixty day period were 
reviewed.  Finally,  five charts of living patients were randomly  selected and contacted for 
personal  conversations  regarding  their understanding  of the information  they received on 
advance  directives.  If five or fewer patients we~  admitted during the time period,  all 
living patients  were  contacted  and interviewed.  Data were collected  between May  11 and 
June 4,  1992. 
4  I Number  of  I  Number of  Number of  1  Number of 
Counties  Facilities  Charts  Patient/Individuals 
Visited  Reviewed  Reviewed  Interviewed 
Hospital  12  24  591  120 
Nursing  Facility  12  24  424  113 
Home Health  Agency  12  24  538  115 
t 
~TOTAL  I  12  I  72  I  1553  I  348 
The data collected  pertained  to the presence or absence of specific materials  and policies 
within the organization,  the documentation of speciilc interactions  and educational 
activities  in the patient  chart and elsewhere,  and the patient understanding  of information 
provided  based on phone conversations  with patients and other relevant individuals.  In an 
effofl to understand  facility/agency  outcomes,  information was also obtained  regarding 
difficulties  facilities  encountered  in implementing the requirements  of the advance 
directive  provisions. 
Information  reported  for the facilities and patient understanding are based on the sample 
data.  Information  presented  on data from the charts is weighted and projected  to the 
universe  of all Medicaid/Medicare  participating  hospitals, nursing facilities  and home 
health agencies.  lhis projection  represents 6.8 million charts.  While some of the 
projections  have poor precision  due to the limited number of facilities and the four stage 
sampling technique,  it is still felt that they represent a reasonable  estimate of initial 
implementation  effom.  Appendix B presents the unweighed  and weighted  sample data 
for the data presented  on patient charts.  Regression analysis was also undertaken  on the 
sample data,  with a cursory  discussion included in the ~rt  and a more complete 
discussion  of the regression  results in Appendix A. 
We conducted  our review according to the Quality Standurds for  Inspections  issued by the 
Presidents  Council  on Integrity  and Efficiency. 
5
 FINDINGS 
MOST  OF THE SAMPLE FACILITIES ARE COMPLYING WITH THE GENERAL 
LEGISLATIVE  REQ~TS. 
Measures  of Compliance With the Advance Directive  Provisions 
Used to Form The Legislative Requirements  Index*. 
~o  The facility has developed written policies and procedures 
explaining advance directives and the hospitals requhvments 
pertaining  to them. 
69    The facility has developed writien materials  regarding  advance 
directives  and provides them to each adult patient upon 
admission or commencing  services (both must be answered  yes 
to obtain credit for this item.) 
x.	 Materials  provided to the patient clearly  state that a patient 
does not require  an advance directive  to receive treatment. 
69    Materials  provided to the patient include a written explanation 
of the law pertaining  to advance directives  in that State. 
67    The facility has provided  staff education  on the advance 
directive  provisions,  and has some form of documentation 
indicating education has been provided  (both must be answered 
yes to obtain credh for this item.) 
fio  The facility has planned or provided community  education  on 
advance directives. 
.  -----.J..-..-i!-- ,.- .....  ..  ...  ...... --- 
numoefs  presenteu  m uaucs  represent  number  01 facmucs  mccung  uus fequmemem -----UUL0?-- a total--- -ot  /2 
Figure 1 
Eighty-seven  percent  of the facilities  demonstrate compliance in five or more of the index 
areas,  and all facilities  demonstrated  compliance  in at least four of the index areas. 
Forty-three  percent  of the facilities  demonstrated  100 percent  compliance  in the legislative 
requirements  index.  When examining facility type,  it is noted that hospitals have the 
highest mean index,  5.5,  nursing facilities have a mean index of 5.3 and home health 
agencies  scored the lowest,  with 5.0 on the six point index.  This demonstrates  very little 
overall difference  between  facility types in complying with the gened  legislative 
requirements.  The index total was derived by assigning one point to each of the six 
legislative  requirements  listed in figure one.39a 
6  The Legislative  Requirement  Most Frequently Umnet Was The Facility Responsibility 
To Provide  Community  Education. 
Twenty-three  of the 72 facilities in the sample, or 32 percent,  had not planned or provided 
community  education  on the advance directive provisions.  Home health agencies were the 
type of facility  which most frequently  had not provided community education.  Twelve 
home health agencies,  or half of the home health sample, had not provided  this sexvice. 
While many facilities  had not provided community education,  half of the seventy-two 
facility contacts  stated more information  needs to be given to the pubIic.  Such public 
information  would increase  awareness of advance directives before individuals became ill 
and improve  understanding  of the terms when directives were explained.  Generally, 
contacts at the facilities  called for public service announcements on this topic and said 
government  agencies,  such as HCFA and Social Security,  should include information 
regarding  the topic  with current  mailings. 
THE LACK  OF CLEAR AND CONSISTENT DOCUMENTATION  IN PATIENT 
CHARTS INCREASES  THE POSSHKLITY THEIR TREATMENT WISHES MAY 
NOT BE FOLLOWED 
Many Sample  Facilities  Had Missing Documentation Regardkg  Whether Or Not The 
Patient Had An Advance Directive. 
Only 19 facilities,  or 26 percent  of the sample, had clear documentation  stating whether 
the patient  did or did not have an advance dmtive  in 100 percent  of the medical rezords 
reviewed.  By contrast,  in 15 percent  of facilities less than half of the charts were clearly 
documented,  including  one of four nursing homes and one of five home health agencies. 
PERCENTAGE  OF CHARTS WITH DOCUMENTATION  PRESENT: 
BY FACILITY 
Below  50 percent  50-75 percent  75-99 Percent  100 Percent 
# of  % of  #of  % of  #of  % of  #of  % Row 
Facilities  Total  Facilities  Total  Facilities  Total  Facilities  Total 
All Facilities  11  15.3  11  15.3  31  43.0  19  26.4 
Hospitals 
o  0  5  20.8  14  58.3  5  20.8 
Nursing 
6  25.0  3  12.5  7  29.2  8  33.3 
Facilities 
Home 
Health  5  20.8  3  12.5  10  41.6  6  25.0 
Agencies 
7

.  While three  facilities  had no documentation  in the medical chart as to whether a patient 
had an advance  directive,  two of these facilities did have documentation  in the patients 
financial folder,  located in the business office.  Additionally,  some facilities  would clearly 
document  that patients  had received  information  regarding advance directives,  but would 
not consistently  document  whether or not the individual had a directive. 
A statistical examination  of the percent  of charts with documentation  present provided 
only limited insight (explaining  13.5 percent  of the variation among facilities)  into which 
factors affect the presence  of clear chart documentation  in each facility.  The three factors 
having an impact on explaining the percentages  of charts with documentation  in each 
facility were: 
  The lack of staff education or documentation  of staff education  on the topic 
  The provision  of staff education after the provisions  were implemented 
  Status as a for-profit  organization 
Facilities  providing  staff education on the topic tier,  rather than before,  implementation 
of the advance directive  provisions  had a lower percentage  of charts with documentation 
present.  This supports the effectiveness of employee education and its impact on 
improving employee  awareness  and attention to this new procedure,  supporting  the need 
for the education  requirement.  The effect of the for-profit variable  was positive,  when 
compared  to not-for-prufit  facilities,  indicating a higher frequency  of documentation  in 
for-profit  agencies.  This finding could indicate for-profit  organizations  may be members 
of a chain and thus more likely to have received company-wide policies  and materials  that 
could be easily disseminated. 
After  accounting  for the States included in the sample, two additional variables,  location 
in Florida  and whether the facility was a nursing home, had a signifkant  negative  impact 
on the percent  of charts with documentation present.  By controlling  for the individual 
States in the regression  analysis,  the variables examined explained 23.8 percent  of the 
variation  in documentation  between the facilities.  There was no signifkant  effect of 
whether the facility  was a hospital,  or home health agency,  location in one of the other 
sample States,  or from  having a higher score on the legislative index in either analysis. 
For a further  discussion  of the statistical findings,  see Appendix A. 
In Sample Facilities,  Information  On Advance Directives Was Often Difficult  To 
X.mate Due To A Lack of Standardized Methods of Documenting. 
Standardized  methods  of presenting  chart documentation,  within a facility,  regarding 
advance directives  may be an important  issue in assuring the ability to locate information 
stating whether  or not the patient  has a directive.  In an emergency  situation,  the ability to 
quickly  locate this information  would be important,  as it could lead to dfierent  treatment 
approaches.  When examining  documentation  methods it was noted that sample facilities 
documented  in a variety  of ways.  When documenting in the chart,  facilities  generally 
used a standard  form  (either computer  generated or photocopied),  a written note in the 
8  chart  (generally  in the social service section or nurses notes), or a standardized  admissions 
assessment  form  utilized by the State in nursing facilities.  Difficulties  sometimes ~ose  in 
locating the documentation  since methods were not always consistent within the facility. 
In addition,  several  facilities may have kept documentation on a standardized  form in the 
business office exclusively,  or in the business office with a note appearing  in the patients 
chart.  Many  facilities  had utilized various methods of documentation  and had moved 
toward a more  standardized  facility format during the early months of the implementation. 
Performance  In Clearly And Consistently Documenting In The Chart Needs 
Improvement. 
STATUS  OF DOCUMENTATION  IN PATEiNTS  MEDICAL  RECORD 
a 11 
J 
Facility  Do cumentation  No Chart  Documentation  Unknown  Comprehension 
Type in Chart  Documentation  Elsewhere  Noted  Poor Noted 
All Types  80.5 %  14.0%  1.7%  3.3%  .2%

Hospitals  86.2%  9.4%  o  4.4%  o

Nursing 
46.0%  25.5%  26.7%  o  1.8%

Facilities

Home

68.0%  31.5%  o  .03%  .5%

Health 
= 

While the majority  of chaxts had clear documentation stating yes the patient  has an 
advance  directive  or  no the patient does not have an advance directive,  many charts 
lacked any documentation  or contained ambiguous statements.  In addition,  some ch~s 
contained  uncompleted  directive  forms,  or only documentation that information  on 
advance  directives  had been provided to the patient. 
When examining  provider  types and their documentation efforts,  some dflerences  become 
apparent.  Almost  one-thid  of the charts in home health agencies and one-fourth  in 
nursing  facilities  had no clear documentation  indicating whether the patient dld or did not 
have a directive.  Additionally,  about one-fourth of the charts in nursing facilities had 
documentation  regarding  the status of the patients pmfenmce  for a directive,  but the 
documentation  was in a location that was inaccessible after working hours.  While this 
indicates  the agencies  have made some effort to document,  documentation  problems  create 
situations  where  the wishes of the patient may not be followed,  due to either the lack of or 
inaccessibility  of information. 
Pregnant  women  were the largest category of patients in the sample lacking documentation 
of directives  in their  medical charts.  Of the 116 women in the sample with dmgnoses of 
pmgn~cy  or nAated to pregnancy,  41 had no documentation  in the~  chart and 8 had 
notations  stating  unknown regardiig  the presence of an advance directive.  Two 
facilities  stated they did not give information to pregnant women,  since provisions  of 
advance  directives  were not applicable while a woman was pregnant.  Other facilities 
9  stated information  was provided  to pregnant  women, but they could be missed,  since they 
were often admitted  through the emergency  room or directly to the floor.  Although many 
hospitals had a policy of following up, to determine if the patient  had a directive,  the 
information  in the chart was often not updated to reflect the follow-up. 
Many State laws indicate advance directives  do not apply during a womans pregnancy,  if 
it appears that her baby may be able to go full term.  However,  the need to ~form 
pregnant  women of advance directives  is still important.  If a pregnant  woman,  not 
informed of her right to an advance directive,  should experience  a tragic outcome,  her 
wishes regarding  continued  life support,  after the delivery of the baby,  would be 
unknown.  This could be equivalent to denying the pregnant  woman an opportunity  to 
make decisions regarding  her medical treatment,  which was the intent of the provisions. 
Another group of patients,  whose charts frequently lacked clear documentation  regarding 
advance directives,  were those patients who were confused or very ill and were not 
accompanied  by a friend or family member during admission.  Without  such assistance or 
counsel,  it was dfilcult  or impossible for the facility to obtain accurate  information  on 
patients advance directive preferences. 
In telephone  interviews  with individuals whose charts had been reviewed,  several said they 
had a directive  while the information  in the chart did not indicate this.  Thirteen 
individuals whose medkal  charts lacked any documentation,  stated they had an advance 
directive prior  to being admitted for cam.  In addition,  11 individuals with documentation 
that they did not have an advance directive,  stated they did have one prior  to being 
admitted.  While there  is no way of confirming this information,  if true,  it would be 
difficult to comply  with these individuals treatment wishes, due to either the lack or 
inaccumcy  of documentation  in the chart. 
problems  In Clearly Documenting patients  Charts May Result From the Lack of 
Guidelines on Acceptable Documentation. 
All types of facilities  included in the sample had some charts that did not clearly  specify 
yes the patient  has an advance directive or no the patient does not have an advance 
d~tive.  Ambiguous  documentation  and documentation  located outside of the patients 
chart accounted  for approximately  five percent of the documentation  efforts.  When 
examining  documentation  by facility type, about one-fourth of nursing facility  charts had 
documentation  located  outside of the charts and approximately  four-and-a-half  percent  of 
hospital charts  had unknown  specifkd.  In addhion,  a number of the over nine percent 
of  hospital charts  lacking any documentation  were charts of pregnant  women.  In some 
facilities,  persomel  stated pregnant  women were not asked whether they had a directive, 
as they understood  the state law to spec@  directives were not applicable  when a woman 
was pregnant.  These results appear to indkate  facilities are unsure of exactly  what 
constitutes  appropriate  documentation  of whether the patient does or does not have a 
directive. 
10
 Comments made by sample facilities  suppoxt this fmding4*. One facility stated that the 
lack of specific documentation  guidelines  was a problem.  In addition,  personnel  in many 
facilities inquired about the appropriateness  of their documentation  efforts during the chart 
review undertaken  for the study.  Some facilities mentioned problems  clearly documenting 
the required  information  due to the patients condition, admission of patients through the 
emergency  room,  clinics or after hours, and the dfilculty  in obtaining information  for day 
surgexy and short stay patients.  Finally,  some facilities mentioned the difllculty  of 
obtaining clear information  on advance directive preferences  from confused or disoriented 
patients.  In many of these cases,  u~own  or comprehension poor were noted. 
Only 60 Percent Of The Patients With Advance Directives Had Copies Of The 
Directive In Their Medical  Chart. 
Of the charts with documentation  (either in the chart or in the financial folder) indicating 
the patient  has an advance directive,  57.5%  have a copy of the directive  in the chart. 
Approximately  two-and-a-half  percent  of the charts with copies of advance directives  did 
not have documentation  in the chart  stating the patient had a directive.  A note was 
present  in eight percent of the charts indicating where a copy of the advance directive 
could be found and 31.8 percent  of the charts had neither a copy of the directive  nor a 
note stating the location. 
The lack of copies of advance directives  in patient charts is acknowledged as a problem  by 
many facilities.  During  discussions regarding facilities problems or dfi~culties  in 
implementing  the advance directive provisions,  12 specifkd  the difficulty in obtaining 
copies of the directive  for placement  in the chart.  Problems in obtaining directives  mnged 
from patients being requested  to provide a copy of their directive but not doing so, 
patients not being able to obtain a copy due to lack of mobility and not wishing to give an 
original to the provider,  patients not being aware that they should bring a copy of a 
directive  to a facility  upon commencing care,  relatives having to be responsible  for 
obtaining a copy or papers having to be sent out of State in order to obtain a copy of a 
directive  from a relative. 
TWENTY-ONE  PERCENT  OF PATIENTS RECEIVING CARE FROM 
HOSP~AI&  NURSING  FACILITIES,  AND HOME HEALTH AGENCIES HAVE 
ADVANCE DIRECTIVES. 
7 
PATIENTS  WITH ADVANCE DIRECTIVES* 
Total With Directives  Average Age (sample)  Female  Male 
All facilities  21.2%  73  55.5%  42.7% 
Hospital  18.2%  63  48.3%  49.5 % 
Nursing Facility  47.7%  79  58.9%  40.2% 
Home Health  25.1%  76  77.1%  22.3% 
i 
*--numbers may not sum to 100% due to mlssmg sex and age mformauon 
11  Examination  of the data indicates that nursing facility and female patients are more likely 
to have advance directives.  The fact that a greater percentage  of nursing facility patients 
have a directive  is consistent with the common view that advance directives  are documents 
that should be considered  by people who may be approaching  the end of their life. 
Examination  of individuals from the sample with directives,  by age group and diagnoses, 
provided  some additional  insight into the public perception  of advance directives.  Nine 
percent of the patients under age 30,  11 percent  of the patients  between the ages of 36 and 
45, and 20 percent  of the patients between the ages 46 and 55 had a directive.  The 
percentages  continue  to increase with age,  with 34.7 percent  of individuals  over the age of 
85 having a directive.  The diagnoses among individuals having a directive  included  10 
percent  with cancer, eight percent  with a diagnosis of broken hip, seven percent  with 
stroke and five percent  having a diagnosis of congestive heart failure.  While none of 
these diagnoses are exclusively  related to the elderly,  more older people tend to have these 
medical conditions.  In addition,  each of these has a higher likelihood of mortality  than 
the other diagnoses  in the sample. 
The sample findings indicate the public tends to perceive advance directives  as only being 
appropriate  for the very old and very ill.  This is further supported by comments  made by 
interviewed  individuals  such as,  I was only having a baby,  or I am too young to think 
about that.   Unfortunately,  many of the legal cases which brought this issue to the 
attention of the public involved young pemple.  These individuals met with tragic 
experiences  resulting  in the extended use of life-sustaining measures,  beyond what their 
family members  felt the individual would have wanted.  These findings also support the 
need to provide public  education on the topic of advance directives. 
TWO  THIRDS  OF THE INDIVIDUALS INTERVDIWED HAD SOME 
UNDERSTANDING  OF ADVANCE DIRECTIVES. 
Percent  of Individuals  Interviewed  With Understandimz of Advance Directives 
a ~ 
E@w!L_Jl 
Patient  Relative  Relevant Individual  Overall 
I 
t 
All Types  63%  74%  89%  67.5 % 
Hospital  61%  77%  (not applicable)  64% 
Nursing Facility  71%  71%  83%  72% 
Home Health  60% 77%  100%  67% 
Interviews  were held with 348 individuals whose charts were randomly  selected from each 
facilitys original  sample,  Of the individuals interviewed,  130 were former  patients,  209 
were family members,  and nine were friends,  caretakers or lawyers.  The interviews 
indicated that 235 of the individuals had some understanding  of advance directives  or 
related terms  such as, living will, durable power of attorney for health care,  proxy, 
12  surrogate or patient  advocate.  Understanding  was judged to be present  if the individual 
could either give at least a simple definition of the term advance directive,  living will or 
durable power of attorney,  or if they volunteered information regarding  their previous 
familiarity or experience  with an advance directive. 
It is noteworthy  that patients as a group included the smallest percentage  of respondents 
with an understanding  of advance directives.  Only nursing home patients demonstrated 
understanding  equivalent  to that of family members.  Facilities reported patient 
understanding  often is very poor upon admission, due to the anxiety surrounding  their 
health condition and the number of papers presented to them.  Reinforcing  this point is the 
fact that 10 percent  of patients who could not recall what an advance directive  was 
mentioned they were too ill, too upset or were bombarded by too many papers  at 
admission.  Furthermore,  12 percent  of individuals stated they did not remember  receiving 
information on the topic,  and 16 percent  stated they did not receive information  on 
advance directives  upon admission.  This supports the suggestion of 17 facilities  that the 
provision of information  on advance directives  should begin before the patient  is admitted 
for care. 
Nursing facility patients  had the highest understanding of advance directives  among patient 
respondents.  This might be a function of the generally long stays associated with nursing 
facilities which allow more time to explain and re-explain advance directives  as necessary. 
It may also indicate  that the average population in nursing homes, frail elderly people, 
have considered  this topic prior  to arriving at the nursing facility.  Also, many individuals 
receiving care from a nursing facility may demonstrate greater knowledge and education 
on the topic because they view it as more relevant to their lives. 
Of the individuals  with understanding  of advance directives,  186 could provide at least a 
simple deftition  of either  living will or durable power of attorney for health care 
without prompting.  A larger percentage  recalled  living will.   For example,  77 percent 
correctly  defined a living will, while 55 percent defined a durable power of attorney  for 
health care.  Four percent  of individuals provided an incorrect dettition,  although they 
thought they understood  the term,  and two percent of the individuals stated they had an 
advance directive,  when they actually had a general or durable power of attorney  with no 
health specifkations. 
Six facilities  specifka.lly  mentioned the problem of patient difilculty  in understanding  the 
information  due to the different terminology used, or the similarity between advance 
directive terms  and other legal terms.  Facilities also noted some patients confuse living 
wills with wills and confuse durable power of attorney for health care with a durable 
power of attorney  related  to financial areas.  This concern was reinforced  by some 
respondents  who when asked to define the terms gave the deftition  of a will,  or dumble 
power of attorney  for financial affairs.  Eight facilities suggestcxl using uniform  language 
and simpler terms  in an effort to encourage greater understanding of advance dmtives. 
The need for a public  information  campaign by the Secretary of Health  and Human 
Semites,  as called  for in the legislation,  was supported by comments made by facilities. 
13  Many facilities cited the need to provide a greater  opportunity  for public education  on the 
topic to improve patient  understanding  of advance directives.  The.t also indicated that 
education  should be provided  at a variety of levels.  Facilities  cited early education  in 
schools, providing  information  through  large community and government  organizations 
and using televised public service announcements  as ways of reaching  more people. 
Additionally,  ten facilities  felt physicians  should be more involved in discussing this area, 
as they are generally  the patients  initial contact with the health system. 
We Found No Evidence  Of Patients Being Pressured To Have Advance Directives. 
A concern voiced by Congress and others before the advanced directive provisions  were 
enacted was that patients would either feel that they were required  to have a directive to 
obtain treatment  or this would be subtly communicated  to patients.  In addition,  there was 
concern that poorer  or more disadvantaged  patients might be encouraged  to have a 
directive.  Two steps were taken to examine this concern.  First,  we reviewed  materials 
provided  to the patient  by each facility to see if a clear statement that a directive  was not 
required  was present.  Second,  in interviewing  patients and family members  we 
specifically asked if they had to have a directive to receive treatment.  Our review showed 
78 percent  of the materials  clearly  stated that a patient was not required  to have an 
advance directive  to receive treatment.  Similarly,  our interviews detected only one person 
who felt they might have been required to have a directive to receive treatment.  Finally, 
a review of the data indicated that Medicaid patients,  genemlly poorer  and more 
disadvantaged,  consistently  were the least likely to have a directive.  Ilk  would indicate 
they were not more likely to be encouraged  to have a directive  when compared  to other 
groups. 
Only 32 Percent of the Facilities Provided Additional Information  ItI Materials  To 
Promote Patient Understanding  Of And Comfort With Advance Directives. 
An examination  of facility efforts to alleviate the concern that patients  might feel 
pressured  to have an advance directive  was also undertaken.  This examination  imokd 
reviewing  the content  of advance directive  materials provided to patients  upon admission. 
To determine  if facilities  were clarifying  that advance directives  were not required  in 
order to receive  care,  could be revoked at any time and should be carefully  considenxi, 
we developed  an index to examine facility efforts in communicating  this information. 
This index was called the quality index.  The quality index contained  three items and was 
used to check whether  materials  provided to patients: 
1.	 Mention  the need to dkcuss  treatment preferences  w~th family and friends 
in case they should have to make medical decisions for the patient; 
2.  State the patient  has a right to revoke the advance directive  at any time; and 
3.	 Advises patients that the facility has blank advance dmtive  forms for their 
use upon request. 
14  The data from sample facilities  indicates there is a need to improve facility performance  in 
providing  information  to increase patients  understanding and level of comfort  with 
advance directives.  For example,  22 percent  of the facilities met none or only one of the 
three items and only 32 percent  of facilities met all three indices.  Once again,  including 
these items in materials  could increase patient understanding of advance directives,  an area 
which facilities  noted as needing improvement. 
Percentage  of Facilities  Including Quality Information  in Patient Materials 
Facilities  Quality Index Scores for Facilities 
Zero  One  Two  Three 
All Types  4.1%  18%  45.8%  31.9% 
Hospitals  o  20.8%  54.1 %  25.0% 
Nursing Facilities  4.1%  16.6%  37.5 %  41.6% 
Home Health  Agencies  8.3%  16.6%  45.8%  29.1 % 
II 
Receiving  Information  On Advance Directives Appeared To Have Some Impact On 
Patients Interest In Obtaining A Directive. 
Being informed  of the right to have an advance directive,  and receiving information  on the 
topic, did appear  to influence  some of the patients who were interviewed.  Seventy-three, 
or 20.9 percent,  of the individuals interviewed said they would consider getting a directive 
after hearing  about them.  In addition,  14 (or four percent of the individuals) actually 
executed a dinxtive  after nxeiving  treatment. 
This finding underscores  the importance  of discussing advance directives  with patients 
before they become  ill.  The  appropriate  place to begin this process  may be in the 
physicians  oftlce,  since they are often the initial patient contact with the health care 
system.  Once again,  this lends support to the suggestion of ten facilities,  that physicians 
become more  involved  in discussing advance directives with patients.  Further,  this 
finding also supports  the need to provide general public education on the topic,  to 
encourage  people  to both think about and discuss advance directives  with relatives  or 
friends. 
15
 RECOMMENDATIONS 
While the majority  of facilities  reviewed  have met many of the requirements  of the 
advance directive  provisions  within the first five months of implementation,  some areas of 
concern exist regarding: 
  patient  knowledge and understanding  of advance directives 
  facilities  documentation  of advance directives  and 
  the presence  of the directive  in the chart. 
Because advance directives  are a complicated  topic not falling neatly into one arena,  a 
coordinated  effort  should be considered  in addressing these concerns.  This effort should 
involve the State agencies  and intermediaries  involved with the Medicaid  and Medicare 
progmm,  as well as involved outside agencies.  Assistance for facilities participating  in the 
Medicaid or Medicare  programs  should also be available from the HCFA,  the agency 
writing the Federal  rules and regulations pertaining to the advance directive  provisions. 
This would increase  the potential for consistent interpretation  of the requirements. 
The coordinated  effort  should also include the Joint Commission for Accreditation  of 
Health Organizations  (JCAHO).  Much of the determination  of compliance  with the 
provisions  will be left to the JCAHO in facilities they accredit.  While  the JCAHO  has 
specific review items pertaining  to the provisions,  including the presence  of a dmtive  in 
the chart,  they do not include simple documentation of whether the patient  has a directive. 
Since findings of this inspection indicate that  11 percent of patients  with advance 
directives  did not have this documented  in their chart, and 20 percent  of charts  lacked 
CIW documentation,  support is present for a geneml documentation  item.  The lack of 
such documentation  weakens the ability to both know and comply with patient  wishes. 
To assure patient participation  in some of the most delicate issues confronted  in health 
care,  we make the following recommendations: 
The HCFA should develop and issue specillc  regulatory guidelines clarifying 
acceptable  documentation  methods to assist providers in meeting the requirements  of 
the Federal Statute.  The guidelines could be incorporated in the Final Regulations 
which are currently  pending,  and should specifically address what constitutes 
acceptable  documentation  of whether a patient does or does not have a dmective. 
Alternatively,  the HCFA could disseminate documentation guidelines through  other 
options: 
  A program  memorandum  from HCFA to State Medicaid  Agencies  and Medicare 
Fkal  Intenmidaries  specifying documentation requirements. 
  Medicaid  Agencies  and Medicare  Intermediaries  could provide  a notifkation  letter 
to all participating  facilities on documentation requirements. 
  Participating  facilities  could be informed of Medicaid  and Medicare  contacts who 
can provide  technical  assistance on specillc documentation  requirements. 
16  The HCFA should encourage the JCAHO to examine if the medical record for each 
patient documents whether or not the patient has an advance directive.  lbis would 
be in addition to the existing JCAHO  review item regarding the presence of a copy of 
the advance directive  in the chart. 
The HCFA,  along with other appropriate  departmental offices,  should provide 
leadership to develop a coordinated Department of Health and Human Service plan 
for educating the general public on advance directives. 
The education plan should  1) address the statutory requirement  for the Secretary  to lead a 
national public  information  campaign on this topic, 2) incorporate  a variety of means for 
conveying  the message in a cost-effective  manner and 3) should involve all appropriate 
DHHS components  (The Social Security Administration  (SSA), The public Health  Service 
(PHS), The Administmtion  On Aging (AOA), The Administmtion  For Children and 
Families  (ACF),  The Assistant Secretary  for Public Affairs (ASPA), etc.).  Options for 
developing  a public  education plan might include: 
  A public  information  campaign to increase understanding of advance directives 
which could include: 
Encouraging  the development of Public Semite  Announcements  regardiig 
advance directives.  The department could consider providing  such 
announcements  in conjunction with national organizations  of health care 
providers  or advocacy groups. 
Encomaging  professional  organizations to provide community education on 
the topic in conjunction with local health care facilities. 
Developing  generic informational  materials which could be provided  to a 
variety  of agencies. 
	 A coordinated  effort involving all relevant agencies to provide uniform information 
on advance  directives  to individuals receiving program  senices  or benefits from 
the HCFA,  SSA, PFIS, AOA, ACF, and the ASPA.  Generic information,  such as 
that included  in the  1993 Me&are  Handbook,  could be used by other agencies in 
booklets,  public  materials  and mass mailings. 
	 Encou@.ng  coordinated  State and private efforts to provide the public with a 
means of canying  information  on their person to alert physicians or facilities  that 
they have an advance directive  including: 
Investigating  the possibility of a check-off box on drivers  licenses for 
individuals  with advance directives,  in conjunction with the State Motor 
Vehicle  Departments. 
Discussing  the development of bracelets or neck chains,  similar to those 
available  to people with speci.flc health conditions,  to indk.ate an individual 
has an advance directive,  with various groups whose purposes are to 
promote  hedthlmedieal  awareness and provide public information. 
17  SUMMARY  OF AGENCY COMMENTS AND OIG RESPONSE 
We solicited and received  comments  from the HCFA on the draft report.  The complete 
text of the HCFA  comments are contained in Appendix C. 
The HCFA concurred  with our recommendation  to provide leadership  in educating the 
public on advance directives,  but suggested that the Assistant Secretary  for Public Affairs 
(ASPA) take the lead role in coordinating  this effort.  The HCFA also concurred  with our 
recommendation  to work with JCAHO to include a spedlc  review  item to determine  the 
presence of documentation  in the medical record that indicates whether or not a patient 
has executed an advance directive.  However,  based on conversations  with JCAHO,  the 
HCFA believes this item has been addressed in the accreditation  process.  The HCFA  did 
not concur with our recommendation  to develop more specific guidance on chart 
documentation,  expressing  concerns that such guidance might be overly prescriptive  and 
reduce provider  flexibility. 
While we appreciate  HCFAS concerns about overly prescriptive  guidance,  we continue to 
believe that additional  guidance is needed.  Although we believe that HCFAS interim 
final rule will assist facilities  in complying with the law, some questions still remain.  We 
found seveml situations in which it might be dfilcult  to document whether or not patients 
had executed an advance directive.  For example,  some patients  mental status may not 
allow them to provide  the needed information  upon admission and they may not be 
accompanied by an individual who is knowledgeable about their personal  affairs.  In other 
situations,  State laws may lead to misunderstandings  regarding the need to collect this 
information.  For example  some hospitals,  in States where an advance directive  may not 
be implemented  during a womans pregnancy,  do not even ask pregnant  women whether 
or not they have an advance directive  when they are admitted.  In still other 
circumstances,  nonstandard  or emergency  admissions may create problems  in obtaining the 
necessary  information.  For example,  when individuals are admitted either after hours or 
directly to a hospital unit they often bypass the process for obtaining information  on 
advance directives.  We believe that more spe.ciflc guidance would help facilities  handle 
these situations and comply with the statute.  This guidance need not be any more 
prescriptive  than the guidance already  contained in the interim final rule, but would only 
be more expansive  in requiring  that these subjects be addressed along with other topics. 
Based upon HCFAS comments  regarding  our recommendation  on JCAHO  reviews,  we 
have revised the wording of our recommendation.  It was our intent to recommend  that 
JCAHO,  in their review  of a sample of medical recotis,  examine the records  for 
documentation  of whether  or not patients have executed an advance directive,  in addition 
to their current  review of whether an advance dtitive  is present  in the chart.  As HCFA 
states, currently  the JCAHO reviews medical records to determine  only if an advance 
directive  is pment  in the chart,  an item that is not a Federal  requirement.  In contrast,  the 
Federal  statute requires that facilities  document... whether or not the individual  has 
executed an advance directive.  The absence of an advance directive  may indicate a 
number of possible  scenarios.  It may indicate that an individual does not wish to execute 
an advance directive,  or that an individual was not informed that s/he has a right to have 
18  an advance directive  or that an individual  has an advance directive  but a copy has not been 
placed in the medical  record.  In fact, our study shows that 40 percent  of persons with 
advance directives  fell into this latter category.  We believe that a speci.ilc documentation 
requirement  to indicate  whether or not an advance directive was executed,  as the statute 
requires,  would better  ensure that medical records contain meaningfid information  about a 
patients decision concerning  an advance directive.  Such documentation  would also better 
ensure that a patients  wishes are known to providers  when making treatment  decisions. 
We support the HCFAS suggestion that other appropriate depalmental  members  should 
participate  in the public education  effort on advance directives.  However,  because 
primary  authority  for the advance directive provisions lies with the HCFA,  and they have 
established  relationships  with the providers  affected by the prevision,  we feel the HCFA 
should be responsible  for negotiating  with the suggested departmental  components, 
including ASPA,  to decide who should coordinate and participate  in this campaign.  We 
have revised our recommendation  accordingly. 
The HCFA  also raised  questions concerning: 
*  whether  we had reviewed facilities compliance too early in the process; 
	 whether the reason for lack of documentation in medical charts arose from 
lack of understanding  of State laws, the patients condition,  or the mode of 
admission,  rather  than confusion about what constitutes acceptable 
documentation;  and 
o	 whether  the low level of documentation we found is consistent with our 
statement that most facilities are complying with legislative requirements. 
We recognize  that we have reviewed  facilities compliance with the statute 4 to 5 months 
after the effective  date,  and  1 month after HCFA issued its dmft regulations.  It was 
indeed our intent to psesent information  on facilities experiences and efforts as they f~st 
began to implement  the statutes requirements.  While it is logical to assume that 
compliance  increases  with experience  and knowledge on the part of providers,  some of the 
problems  that arise  in the early stages of implementation--if addressed quickly--can  best 
ensure smooth realization  of new requirements  over time.  Additionally,  we also =o@tie 
that the HCFA  issued Program  Memomn&  in October and December  of 1991 to inform 
all facilities  and State Agencies of the requirement  to implement the self determination 
legislation  by December  1, 1992. 
Based on HCFAS comments  regarding  the possibility that factors other than confusion 
about acceptable  documentation  might have contributed to poor documentation,  we have 
refined our sub-fmdmg  on this point. 
Finally,  we appreciate  HCFAS point about whether facilities are generally  complying  with 
legislative  requirements  if they are not meeting documentation requirements.  However, 
we indicate that in our review,  facilities  were in fact complying with many aspects of the 
19  legislation,  with the requirement  regarding  documen~tion  being the most obvious 
exception.  It is for this reason that these issues were separated  and our first two 
recommendations  are directed  at strengthening  guidance and technical assistance  in this 
area. 
20
 ENDNOTES

1.  ~eadvmce  dkective  provisions  wemenactti  as S~tions42O6md475l  of the 
Omnibus Budget Reconciliation  Act of 1990, Public Law 101-508.  The original  bill, 
referred  to as the Patient Self Determination  Act, was introduced as S. 1766 by Senators 
Danforth  and Moynihan  and H.R.  5067 by Congressman Sander Levin. 
2.	 Levin,  Sander,  D. MI, Remarks  in the House of Representatives  on H.R.  5067: 
Patient Self-Determinationj  Thursday,  Jun 28,  1990, CR page E-2190. 
3.  McCloskey,  Elizabeth  Leibold,  The Spirit of the PSDA,  Practicing fhe PSDA, 
Hastings Center,  Sept-Ott  1991, pg S14. 
4.	 Rouse, Fenella,  Patients,  Providers,  and the PSDA, Practicing the PSDA, Hastings 
Center Report,  Sept-Ott  1991, pg S2. 
5.  Rouse,  Fenella,  ibid. 
6.  McCloskey,  Elizabeth,  The Patient SeLf-Determination Act, Kennedy Institute  of 
Ethics Journal,  I, no. 2,  1991, pg 163-69. 
7.  OBRA 1990, P.L.  101-508, section 4206, Conference agreement,  pg.  129. 
8.  Rouse, Fenella,  ibid. 
9.  Nancy Beth Cruzan,  by her Parents and Co-Guardians,  Lester L.  Cruzan,  et UX, 
Petitioners  V Di.nxtor,  Mssouri  Department  of Health, et al.,  U.S.  Supreme Court 
Reports,  1990, 497 US -,  111 L Ed 2d 224,  110 S Ct-, no. 88-1503. 
10.  Legislative  History,  House Report No,  101-881, sec. 4122, pg.  88. 
11.  Bedell,  Susanna E.,  and Delbanco,  Thomas L.,  Choices Abut  Cardiopulmonary 
Resuscitation  in the Hospital,  When Do Physicians Talk With Patients?,  Z7zeNew 
England Journal  of Medicine,  1984, Vol 310, no.  17, pgs.  1089-1093. 
12.  Jonsson,  McNamee,  and Carnpion,  ne  Resuscitate  Order A Profde  of Its 
1)0  Not 
Changing Use, Archives  of Internal Medicine,  Nov  1988 pg.  2373. 
13.  Bedell,  Susanna E. et al.,  Do Not Resuscitate Orders for Critically Ill Patients  in the 
Hospital,  How Am They Used and What is Their Impact, Joumal  of the America 
Medical  Association,  July 1986, vol. 256, no.2,  pgs 233-237. 
14.  Bedell & Delbanco,  ibid. 
15.  Jonsson,  McNamee,  & Campion,  ibid. 
21  16.  Bedell et al,,  Ibid. 
17.  Uhlrnann,  Richard  F.,  et al.,  Physicians and Spouses Predictions  of Elderly  Patients 
Resuscitation  Preferences,  Journal  of Gerontology,  1988, Vol 43, no. 5, Ml 15-121. 
18.  Ouslander,  Joseph,  et al.,  Health Care Decisions Among Elderly  Long-term  Care 
Residents and Their  Potential  Proxies,  Archives  of Internal Medicine,  June  1989, vol 
149, pgs 1367-1372. 
19.  Uhlmann,  et al.,  Ibid. 
20.  Ouslander,  et al.,  Ibid. 
21.  Emanuel,  Linda and Barry,  Michael,  et al.,  Advance Directives  For Medical  Care --
A Case For Greater  Use,  The New Englund Journal of Medicine,  V01324,  N0.  13, pgs. 
889-895, 
22,  l?ze Righl  To Die: Times Mirror  Center forthe  Pwplemd  the press,  1990, 
23.  Emanuel,  &Barry,  ibid. 
24.  McCrary,  Van and Bot.kin, Jeffrey,  Hospital Policy on Advance Directives,  Do 
Institutions  Ask Patients About Living Wills?,  Joumai  of the American  Medical 
Association,  Nov.  1989, vol 262, no.  17, pgs 2411-2414. 
25.  McCrary,  ibid. 
26.  McCrary,  ibid. 
27.  Kamer,  R. S.,  et al.,  Effect of New York States Do Not Resuscitate  Legislation  On 
III Hospital  Cardiopulmonary  Resuscitation Practice,  American Journal  of Medicine, 
1990, VO188, pgs.  108-111. 
28.	 Tarnowski,  K. J.,  et al.,  Readability of Pediatric Biomedical Research  Informed 
Consent Forms,  Peditics,  1990, VOI85, pgs. 58-62. 
29.	 Berman H,  Rose L.,  Choosing ~he&ghtHealth are  Plan, Mount Vernon N.Y.1, 
Consumers  Union,  1990, 3. 
30.  Annas,  George J.,  The Health  Care Proxy and the Living Will,  ?%e New EngZand 
Journal  of Medicine,  April  1991, vol 324, no.1 17, pgs.  1210-1213. 
31.  h  Puma,  John,  et al.,  Advance  Directives on Admission,  CliNcal  Implications  and 
Analysis of tie  Patient  Self-Detenni.nation Act of 1990, Journal  of the American  Medical 
Association,  July  1991, Vol 266, no. 3, pgs. 402-405. 
32.  I& Puma,  et al,  ibid. 
22
 33.  La Puma,  et al,  ibid. 
34.  White, Margot  and Fletcher,  John,  The Patient Self Determination  Act,  On Balance, 
More Help Than Hindrance  (editorial),  Journal of the American Medical Association, 
July 1991, vol. 266,  no. 3, pgs 410-412. 
35.  Puma, et al.,  In Reply to Letter to the Editor, Joumul  of lhe American Medical 
Association,  Dec  1991, vol. 266, vol. 24, pg. 3424. 
36.  White & Fletcher,  ibid. 
37.  While individual  State Laws regarding  advanced directives  were not reviewed, 
information prepared  by Charles Sabatino of the Commission on Legal Problems  of the 
EJderly within the American Bar Association (September 1991), Amy Rosenberg,  Editor 
for the AAHA Leml  Memo within the American Association of Homes for the Aging 
(Summer 1991) and a drafl article for Clearing House Review (October  1991) by Charles 
P. Sabatino and Vicki Gottlich,  Seeking Self Determination  in the Patient Self-
Determination  Act,  were used as a guide to State Legislation on the topic. 
38.  For initial sample selection,  States were grouped strictly on the basis of existing 
legislation,  although  legal opinions and case law may also be considered  when determining 
the types of advance directives  allowed in each State.  Based on this selection approach, 
one State, Nebraska,  was excluded from the sample due to lack of legislation pertaining  to 
advanced directives  at the time of the study.  Two additional States, Alaska and Hawaii, 
were excludcxl from the sample due to their distance and cost considemtions.  Although 
Maryland  did have an Attorney  Geneds  opinion recognizing the legal effectiveness  of 
the Durable Power  of Attorney for Health Care, this opinion did not appear in Statute. 
Thus, the DPAHC  in Maryland  was not considered for grouping purposes.  Only the 
living will was considered  for grouping purposes.  Washington has legislation  mgard~g 
both living wills and DPAHC,  and thus was grouped based on this infomnation. 
However,  the legislation  regarding  DPAHC is very limited, allowing a named individual 
to only provide  informed  consent for those treatment decisions previously  specifkd  by a 
patient.  Because both types of directives did appear in statute, Washington  was grouped 
based on the presence  of both  of advance directives,  despite the limits placed  on the 
types 
DPAHC.  Finally,  at the time of the study design, Arizona was characterized  as having 
only a living will statute and was grouped based on this information.  However,  at time of 
data collection  it was noted that information was provided to patients on both living wills 
and DPAHC.  Upon further  clarifkation  from David Iandreth  of the Auizona Medical 
Association,  it was determined  that Arizona enacted a DPAHC statute during the summer 
of 1992, and both living wills and DPAHt2 are now officially recognized.  For purposes 
of this study, the sample States selected were categorized as follows:  1) Florida  and 
Washington,  living will and DPAHC,  2) Maryland and Arizona,  living will,  and 3) 
Massachusetts  and Michigan,  DPAHC. 
39.  The legislative  index developed for use in this study was based on information 
provided  in Public  Law  101-508, section 4206,  1990 Budget Reconciliation,  the draft 
interim  rule,  referred  to in this report as draft regulations dated Febmary  6,  1992, the 
23  Progxam Memorandum  to Intermediaries  dated December  1991, Program  Memorandum  to 
Medicaid State Agencies  dated October,  1991, and information  on page 2 number  690 of 
the Medicare  and Medicaid  Guide in the discussion of the issuance of the interim  final 
rule on advanced directives.  All six of the items are specillcally  mentioned  in the 
requirements  and have been assigned the same weight of one.  An additional  item was 
clearly mentioned  in the requirements,  the need to document  in the patients  medical 
record whether or not they have a directive.  Since data on this specific item was collected 
and discussed at length in other sections of this report,  it was not included in the 
legislative index. 
40.  Since the design of this study and the collection of the data,  an additional  item has 
been clariiled  specifically  as a requirement  in complying with legislation  on advanced 
directives,  This information  was provided  in the Medicare Hospital Manual,  transmittal 
number 641, date August  1992.  The additional requirement  is noted in parentheses  on 
page  134 of the Medicare  Hospital Manual.  The requirement  specifies that facilities  must 
provide written  information  to the patients regarding any conscientious  objection  clause 
the facility might have regarding  implementing  advanced directives,  to the extent it is 
allowed in State law.  A conscientious objection clause refers to the ability of the hospital 
or any agent of the hospital to n%use to implement a directive  as a matter of conscience. 
41.  After  the data collection  for this inspection had been completed  a hospital in 
Michigan contacted  the project  leader about the chart documentation  issue.  The individual 
calling was responsible  for the Medical Records function in the hospital.  She stated other 
individuals with this responsibility  in Michigan hospitals had expressed their concerns 
about appropriate  documentation  in the charts of patients during dkcussions.  She stated 
one of the individuals  involved in the discussion worked in a hospital that had been 
included in the sample for this inspection,  prompting her call.  She wanted to express her 
interest in seeking guidance  on documentation.  She was referred  to individuals  in her 
regional office and HCFA.  This indicates that other facilities have spe.ciflc concerns  about 
documentation  issues. 
24  APPENDICES 
Appendw  A  Regression  Results 
Appendti  B  Weightd  and Unweighed  Chafi DaU 
Appendm  C  Full Text of Agency Comments  APPENDIX  A

Regression analysis  on the sample data was undertaken estimating  two models.  The 
dependent variable  was the percent  of charts in each facility with clear documentation 
stating whether or not the patient has an advance directive.  Our regression  analysis 
detected five factors  (independent vtiables]  that were statistically  signillcant: 
1) status as a for-profit  organization, 
2) the lack of staff education or documentation  of staff education  on the topic, 
3) the provision  of staff education after the Act was implemented, 
4) location in the State of Florida,  and 
5) the provider  was a nursing home. 
There was no signitlcant  effect of whether the provider  was a hospital or home health 
agency,  location in one of the other sample States, or from having a higher score on the 
administrative  index.  See Table  1 for regression results. 
The effect of status as a for-profit  organization  was positive in both models,  meaning they 
were more likely to have a larger percentage  of charts with documentation  present  when 
compared to not-for-profit  facilities.  In the second equation where States were controlled, 
this variable  had the greatest impact.  As many of the for-profit  agencies  were members 
of a multiple facility  system, this could indicate efficiencies in central  development  and 
dissemination of information.  This may allow the facilities in for-profit  multi-facility 
systems to have more  standardized procedures  and forms which could impact the 
documentation  in patient charts. 
The effects of both lack of staff education or having no documentation  that education was 
provided and providing  education after the Act became effective we=  negative  in both 
models.  This indicated that the facilities which provided education after the requirements 
were implemented,  had a lower percentage  of charts with documentation  present  than dld 
facilities  which provided  education before the implementation  of the Act.  The staff 
education variables  had the greatest effect of the signifkant  factors  in the f~  regression 
model.  This could indicate that the education did affect employee awareness  and attention 
to this new procedure,  and reinforces the importance of the education  requirement.  It 
could also indkate  that facilities  that document,  document well. 
In model two, variables  were included to account for the effect of each State.  When 
controlling  for each State in the sample, the effect of a facility located in the State of 
Florida  was negative  and sigrdfkxmt when compared to the omitted category  (which was 
Washington).  Location  in any of the other sample States did not result in any signifkant 
changes.  This indicated that facilities in Florida had a lower percentage  of charts with 
documentation  present.  In addition,  when controlling for States in the sample,  the effect 
of whether the provider  was a nursing home became statistically  signiflca.nt and negative. 
This indicated  &at nursing facilities  were more likely to have a lower percentage  of charts 
with documentation  present  when compared to hospitals, after looking at individual  States. 
A -1
 Table 1 
1

R.EGRESSION  RESULTS:  Percent  of Chalts  in Facil@  With Document&on 
(Model 2) 
(.Model 1) 
percent  Chti 
percent  Chti 
Independent  Compliance 
Compliance 
Variable  per Facility 
per Facility 
5.18 
8.77 
INDEX  (5.67) 
(5.29) 
12.75** 
8.82* 
For Profit  (4.28) 
(4.12) 
4.49 
6.15 
Public  (4.97) 
(5.13) 
-9.05* 
-7.46 
Numi.ngFacility  (4.15) 
(4.37) 
-3.82 
-2.84 
Home Health  Agency  (2.77) 
(2.91) 
-8.08* 
-10.85** 
Ed After Implemen@tion  (3.73) 
(3.83) 
-11.35** 
-10.38* 
No Education  (3.85) 
(3.96) 
1.21 
A-izona  (6.00) 
-9.36* 
Florida  (4.00) 
-3.35 
Massachusetts  (2.81) 
.56 
Maryland  (2.33) 
1.91 
Michigan  (2.05) 
38.21 
24.78 
Constant 
.366 
.220 
R Square  .238 
.135 
Adjusted R Square  2.84* 
2.585* 
F = 
*	 =  sig.  .05  ** =  ig.  01

(stantid  error  presentd  in Parentheses)

A -3

_  APPENDIX  B

WEIGHTED  AND UNWEIGHED  CHART DATA REPORTED  IN THE TEXT 
STATUS OF DOCUMENTA~ON  IN PATIENTS  MEDICAL  RECORD:

Sample/Weighted 
Facility  Documented  Not  Documented,  U~own  Unable to 
Type  in Chart  Documented  But Filed  noted in  Comprehend 
in Chart  Elsewhere  Chart  Noted in Chart 
n 
All TWeS  76 0%/80.5%  18.0%/14.0%  3.2%/1.7%  1.7%/3.3%  1.1%/.2% 
Hospitals 
81.7%/86.2%  14.2%/9.4%  o  4.1%/4.4%  o 
Nursing 
69.1%/46.0%  16.0%/25.5%  12.0%/26.7%  o  2.8%/1.8% 
Facilities 
Home 
74.7%/68.0%  23.8%/31.5%  o  .5%/.03%  1.0%/.5% 
Health 
PATIENTS  WITH ADVANCE DIRECTIV=: 
Sample/Weighted* 
rype  of Facility  Total Patients With  Average 
Advance  Age  Female  Male 
Directives  (sample) 
AUFacilities 
26.6%/21.2%  73  64.1%/55.5%  35.9%42.7% 
Hospital 
20.8%/18.2%  63  60.6%/48.3%  39.1%/49.5% 
Nursing 
40.3%/47.7%  79  67.8%/58.9%  32.1%/40.2% 
Facility 
Home 
22.4%/25.1%  76  62.1%/77.1%  37.8%122.3% 
Health 
1--numbers may not sum to 100% due to md.ng  sex and age mtormatlon 
B-1  APPENDIX  C 
AGENCY COMMENTS: 
HEALTH  CARE FINANCING  ADmSTRA~ON 
c-1 
..  /b@c&L;   -
u 
30= 
DATE 
FROM  Bruce  C. Vladeck

Administrator

SUBJECT  Office  of Inspector  General  (OIG)  Draft  Reports:  Early

Implementation  of the  Patient  Self-Determination  Act

(OEI-06-91-01130),  and Facility  and  Patient  Responses  to  the  Patient

Self-Determination  Act (OEI-06-91-01131)

TO  Bryan  B. Mitchell

P~ncipal  Deputy  Inspector  General

We  have reviewed  the  draft  reports  which present  OIG  findings  on  the  extent  of 
institutional  compliance  with  the  advance  directive  provisions  of the  Omnibus 
Budget  Reconciliation  Act  of  1990 and  patients  understanding  of their  rights  and 
information  provided  to them  in regard  to this  provision.  Our  specific  comments  are 
attached  for your  consideration. 
Thank  you  for  the  opportunity  to review and comment  on these  reports.  Please 
advise  us if you  agree  with  our  position  on the  reports  recommendations  at your 
earliest  convenience. 
Attachment  Comments  of the  Health  Care  Financirw  Administration  (HCFA)  on 
the  Office  of InsDector  General  (OIG)  Draft  Reuorts: 
Earlv  Implementation  of the  Patient  Self-Determination  Act, 
(OEI-06-91-01130)1 
and

Facilitv  and  Patient  Rest)onses  to~e  Patient  Self-Determination  Act,

~OE1-06-91-01131)

Recommendation  1 
The  HCFA  should  develop  and  issue specific  regulato~  guidelines  clarifying 
acceptable  documentation  practices  to meet  requirements  of the  Patient  Self-
Determination  Act.  Guidelines  could  be  incorporated  in the  Final  Regulations  which 
are  currently  pending  and  specifically  address  what  constitutes  acceptable 
documentation  of whether  a patient  does  or does  not have a directive.  The  HCFA 
could  further  disseminate  documentation  guidelines  in the  manner  used  in 
disseminating  initial  information  on the  r~quirements.  For example: 
o	 Program  memorandum  from  HCFA  could be provided  to State  Medicaid 
agencies  and  State  Medicare  fiscal intermediaries  on specific  documentation 
requirements. 
o	 Medicaid  agencies  and  Medicare  intermediaries  could  provide  a letter  to all 
participating  facilities  on documentation  requirements. 
o	 Participating  facilities  should  be  informed  of Medicaid  and  Medicare  contacts 
who can  provide  technical  assistance  on specific documentation  requirements. 
HCFA  Resrmnse 
HCFA  nonconcurs.  We  do not  believe  that  it is prudent  to be  overly perscriptive  in 
this area.  Existing  Medicare  and  Medicaid  regulations  include  specific  requirements 
governing  medical  record  documentation.  Hospital  medical  records  standards 
(42 CFR  48224)  require  the  record  to b~ accurate,  legible, complete,  and 
authenticated.  If the  records  this study identified  as ambiguous  had  been  properly 
authenticated,  staff  could  easily have  contacted  the  author  for clarification.  HCFA 
regulations  also  include  medical  records  requirements  for nursing  facilities 
[42 _  483.75(1):  Records  must  be in accordance  with accepted  professional 
standards,  complete,  accurately  documented,  and  readily accessible],  and  home  health 
agencies  [42 CFR  484.48:  Records  must  be in accordance  with accepted  professional 
standards].  We  believe  these  requi.ranents  are  sufficient  to accommodate 
_   Page  2 
the  advance  directive  requirement;  therefore,  we do not  agree  that  specific  regulatory 
guidelines  are  needed.  If these  facilities  are  not meeting  existing standards, 
promulgation  of new standards  will not solve the problem. 
The  interim  final  regulation  stated  that  there  may be various  ways to effectively  obtain 
the  information  needed  to document  the  medical  record,  but did not address  the 
specifics  of how this documentation  should  be done.  The  flexibility contained  in our 
regulation  is appropriate  because  it encourages  innovation  and  avoids  potentially 
unnecessa~  recordkeeping  burden.  We believe  the focus should  be  on ensuring  that 
providers  comply  with  the  documentation  requirement,  instead  of prescn%ing  the 
method  for documenting  the  existence  of an advance  directive.  Additionally,  while 
we understand  that  many  providers  will collect  copies  of advance  directives,  we do not 
believe  that  the  statute  authorizes  a regulatory  requirement  to do so. 
The  OIG  study notes  that  the  Joint  Commission  for Accreditation  of Health 
Organizations  (JCAHO)  requires  that  aiy  advance  directive  be included  in the 
patients  chart.  We  would  also like to point  out that  the States  also typically  include 
records  requirements  among  conditions  for licensure  for health  facilities.  It appears 
that  the  report  did not  review the  content  of State  advanced  directive  laws.  ~ese 
laws may contain  additional  documentation  requirements. 
Recommendation  2 
HCFA  should  encourage  the  JCAHC) to include  a specific review  item  to determine 
the  presence  of documentation  of advance  directives  in each  patients  chart,  in 
addition  to the  existing  review  items  regarding  directives. 
HCFA  Resnonse 
HCFA  concurs  to the  extent  that  JCAHO  agrees  to any additional  information 
collection  requirement.  It is a longstanding  practice  between  HCFA  and  JCAHO  to 
coordinate  efforts,  where  possible,  on the  rules and regulations  issued  by each. 
We  have  had  discussions  with  the  JCAI-IC) regarding  advance  directive  rules  and  the 
documentation  of such  in the  medical  records,  and  it appears  that  they  have  . 
addressed  this issue.  Specifically,  the  JCAHOS Accreditation  Manual  for Hospitals, 
standard  RI.1.1.3.2.3.,  states  that  any advance  directive(s)  is in the  patients  medical 
record  . . . and  the  scoring  process  includes  review of medical  records.  Page  3 
Recommendation  3  . 
The  HCFA  should  provide  leadership  in developing  a coordinated  Department  of 
Health  and  Human  Services  plan  for  educating  the  general  public  on advance 
directives. 
HCFA  Resuonse 
HCFA  concurs.  We  recognize  that  additional  work remains  in educating  the general 
public  on advance  directives  and  that  HCI?A should  play a key role  in developing  a 
coordinated  plan  for carrying  out  that  educational  activity.  Since this effort  will 
involve several  agencies  within  the  Department,  we believe  responsibility  for this 
action  should  rest  with  the  Office  of the  Assistant  Secretary  for Public  #dfairs 
(OASPA),  in order  that  tasks  can  be  directed  through  the  Departments  chain  of 
command.  HCFA  is nevertheless  willing to provide  staff support  in working  closely 
with the  OASPA  in carrying  out  this actitity. 
Technical  Comments 
We believe  it is contradictory  to assert  that  most  facilities  are  complying  with  the 
legislattie  requirements,  but  at the  same  time  find that  only 26 percent  of facilities 
clearly  and  consistently  document  whether  the  patient  has an advance  directive. 
Significantly,  this report  measured  initial  implementation  efforts  only 1 month  after 
the  regulation  was in place. 
On page  5, the  report  notes  that  some  of the samples  have poor  precision  due  to 
the  small  number  of samples,  but  concludes  that  it is still felt that  they represent  a 
reasonable  estimate  of initial  implementation  efforts.  Further  explanation  of this 
conclusion  would  strengthen  the  repo~  particularly  in light of the  contradictory 
findings  in the  Facilitv  and  Patient  Resnonses  report. 
Most  of the  findings  cited  in the  section  entitled  Lack of Guidelines  of the  Early 
Imdementation  of the  Patient  Self-Determination  Act report  (pages  10 and  11) do 
not  support  the  sections  cmtchsion.  These  findings. indicate  that  facilities  failed  to 
document  whether  an  advanced  directive  existed  because  personnel  did not 
understand  State  laws, because  of a patients  condition,  or because  the  patient  was 
admitted  after  hours  or  through  the  emergency  room  - not due  to confision 
regarding  what  constitutes  acceptable  documentation.  The  Facili~  and  patient 
Resuonses  report  also  indicates  that  the  condition  of the  patient  and  the 
circumstances  of admission  were  the  reasons  given for lack of documentation. 
Marginal  notes  have  been  added  to your  draft  report.  A copy is attached.