Advance Care Planning: Documenting Preferences, Reviews, and Care Team Communication

Preferences Need to Be Known Before They Are Needed

Advance care planning supports a person to communicate values, goals, beliefs, and preferences for future health and personal care. Documentation helps authorised decision-makers and care teams find current information, understand how it was developed, and know when it should be reviewed.

A progress note is not a substitute for a legally recognised advance care directive, appointment, or clinical order. Requirements and terminology vary across Australian states and territories, so providers must use the correct local documents and processes.

Document the Conversation Respectfully

• Who initiated the conversation and why it occurred at that time.
• People the person chose to involve and any communication support used.
• The person's own words about what matters to them.
• Information provided and questions referred to an authorised clinician.
• Consent to share relevant preferences with the care team or representative.
• Formal documents completed, reviewed, requested, or stored in the approved location.
• Next action, responsible person, and review date or trigger.

Example Planning Note

"During today's care plan review, Evelyn asked to discuss what would happen if she became too unwell to speak for herself. At her request, her son Mark joined the meeting by phone. Evelyn said remaining comfortable and having family nearby were especially important to her. The RN explained the service's advance care planning process and referred questions about treatment choices to Evelyn's GP. Evelyn agreed for relevant preferences to be shared with her care team. Existing document status checked; Evelyn requested support to review it with her GP. Appointment request assigned to care coordinator, who will record the outcome and update the document register."

Keep Values Separate From Assumptions

Do not infer preferences from diagnosis, disability, age, culture, religion, or a family member's view. Record what the person communicated and how they were supported to participate. If views differ, document each perspective neutrally and escalate through the approved decision-making process.

Know the Review Triggers

Review may be appropriate after a change in health, diagnosis, decision-making arrangements, care setting, personal relationships, goals, or expressed preference. Routine care plan review can also confirm that documents remain current, accessible, and consistent with the person's wishes.

Make Current Information Easy to Find

The team should know where formal documents and clinical orders are stored, how currency is confirmed, who must receive updates, and what to do if records conflict. Avoid copying entire sensitive documents into daily notes; link to the approved record and document relevant authorised care instructions.

Common Documentation Risks

• Using vague phrases such as "family aware" without the person's involvement.
• Recording a family preference as though it were the person's choice.
• Keeping multiple versions without a clear current document.
• Completing a discussion but not assigning follow-up.
• Failing to communicate an updated preference to relevant staff.

The home care compliance guide provides related guidance on person-centred records, governance, and review evidence.

This article was written by AccuNote's Person-Centred Planning Team for general documentation education. It is not legal or clinical advice; providers should apply current jurisdictional law, consent requirements, professional guidance, and organisational policy.