DA Tracking and Documentation

 

Tracking DA Distribution and Ensuring Return

Documenting DA distribution is extremely important not only to facilitate patient follow-up, but to keep these resources available to the clinic. If the DAs are mailed out or taken home for viewing, you will need a plan to facilitate their return and to allow the patient to discuss the DA with his/her clinician.

We found that using the one page DA tracking sheet facilitated all aspects of DA tracking and return. Moreover, follow-up calls regarding DA viewing and return could be made by the front desk staff using these forms.

You will want to address the following questions as you plan your process:

  • How and when will you ask for the DA to be returned? Who will be responsible for this task? Who will follow up with patients using phone calls or reminder postcards?
  • Who will document in the patient’s medical record that a DA was received — the clinician, the MA/RN, or both?
  • Who will schedule a follow-up visit for the patient? How will the clinician know to discuss the DA with the patient at their next appointment?
  • If you have an EMR, is there an easy way (check box) to document DA distribution and return?

Once the DA distribution and return process has been established it is important to train staff and clinicians in these procedures. Providing this training at a staff meeting or individually and allowing further refinement is an effective strategy.

Documenting Patient Choice

Clinicians each have their own documentation style. Many will choose to document the use of DAs as part of the informed consent process. You can insert a paper form into the patient chart or use an EMR macro or smart phrase. Here is some suggested text:

A decision aid was used to help the patient understand the procedure, alternatives and risks of [condition/treatment]. The patient was able to express their preferences and ask any questions. Together a decision was made to do [insert choice].

 

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