Journal of Patient Safety & Quality Improvement

Journal of Patient Safety & Quality Improvement

Standardizing Advance Care Planning Documentation During Medicare Wellness Visits in a Primary Care Setting: A Quality Improvement Initiative

Document Type : Original Article

Authors
Ronaldo Pichardo-Gonzalez 1
Maryssa Miller 1
Kirby Sullivan 1
Ashley Wong 1
Louisa Whitesides 2
Courtney Paul 1
1 Department of Internal Medicine, George Washington University Hospital, Washington, DC, USA
2 Department of Geriatrics, George Washington University Hospital, Washington, DC, USA
10.22038/psj.2026.91400.1497
Abstract
Introduction:
At our institution, advance care planning (ACP) discussions during Medicare Annual Wellness Visits (MAWVs) were inconsistently documented. While providers often discussed patient wishes, these discussions were often not documented. Standardization of ACP language and documentation provides a foundation to improve communication of patient ACP discussions between outpatient and inpatient settings.
Materials and Methods:
We conducted a quality improvement (QI) initiative in an academic center aimed at improving ACP documentation. A standardized documentation template was developed and embedded in the electronic medical record (EMR), automatically routing content to the ACP section of the chart.  Four Plan-Do-Study-Act (PDSA) cycles focused on provider education, ACP lecture series, mid-level education and patient education were conducted. Outreach to patients via MyDirectives.com and integration with Chesapeake Regional Information System (CRISP DC), a city-wide health information exchange enabling secure sharing of ACP records across institutions.
Results:
At baseline, ACP tool utilization was 0%. Following template implementations and PSDA cycles, utilization increased to 12.9% after PDSA 1, 17.8% after PDSA 2, 24.20% after PDSA 3 and 39.70% after PDSA 4. Providers reported improved workflow integration and greater confidence discussing ACP. Documentation also became more visible and accessible across care settings.
Conclusion:
Implementation of standardized ACP documentation templates in the EMR ensures consistency, clarity and accessibility of patient preferences. Future efforts include implementing the ACP documentation template in inpatient workflows, uploading relevant legal documentation into the EMR, and expanding sharing through regional and nationwide platforms to ensure end-of-life wishes are honored across all points of care.
Keywords
Advance care planning
Medicare Annual Wellness Visit
Electronic medical record
Quality improvement
Standardized documentation
Subjects
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Journal of Patient Safety & Quality Improvement
Volume 14, Issue 2
Spring 2026
Pages 71-76