An advance care planning note records a conversation about future care: what matters most to the patient, who will decide if they can’t, the treatments they would and wouldn’t want, and the forms completed. Copy the free template, see a heart failure visit in primary care and a hospital family meeting for advanced dementia, and check what each part needs.
Blank advance care planning note template
FreeADVANCE CARE PLANNING NOTE Patient: [Name] Date of birth: [Date] Date: [Date] Setting: [Clinic, hospital, home, care home, or video] Start and end time: [Times, and total minutes in the conversation] Clinician: [Name, credentials, role] WHO TOOK PART Present: [Patient, family, decision-maker, interpreter, and team members, with relationship or role] By phone or video: [Names, or none] Why now: [Planned visit, new diagnosis, decline, hospital stay, upcoming surgery, or the patient's request] Patient agreed to: [Who could be present, and what could be shared with them] CAPACITY For these decisions: [Has capacity, lacks capacity, or it varies, and how you judged it] If the patient lacks capacity: [Who spoke for the patient, on what authority, and what is known of the patient's own past wishes] Communication: [Language, interpreter, hearing or vision aids, written materials given] UNDERSTANDING OF ILLNESS In the patient's words: [What they understand about their illness and where it is heading] Information wanted: [How much they want to know, and who they want included] What was shared: [Diagnosis, likely course, and outlook as discussed, with the uncertainty named] Response: [Emotions, questions, and what they took away] WHAT MATTERS MOST Goals and values: [What matters most now, and if their health gets worse] Fears and worries: [What they fear most about the future] Abilities they can't imagine living without: [What makes life worth living for them] Trade-offs: [What they would and wouldn't go through for the chance of more time] Faith, culture, and family: [Beliefs or traditions that shape their choices] DECISION-MAKER Substitute decision-maker or health care agent: [Name, relationship, phone] Alternate: [Name, relationship, phone, or none] How named: [In a legal document, or by the default order where you practice] Knows and agrees: [Whether the decision-maker knows their role and has heard the patient's wishes] Leeway: [Follow these wishes closely, or room to decide in the moment] TREATMENT PREFERENCES Resuscitation if the heart stops: [CPR, or no CPR, and the reasons] Breathing machine and intensive care: [Wanted, a time-limited trial, or not wanted] Hospital transfer: [For any problem, for some problems only, or comfort care where they live] Artificial nutrition and fluids: [Feeding tube or IV fluids: wanted, a trial, or not wanted] Other treatments: [Dialysis, antibiotics, transfusion, an implanted defibrillator, or others discussed] Overall focus of care: [Full treatment, selective treatment, or comfort-focused care] Recommendation: [What you recommended, and why] DOCUMENTS Advance directive: [Completed, updated, reviewed, or none, and where the original is kept] Portable medical order: [POLST, MOLST, or the order used where you practice, with its choices; or not indicated, and why] Resuscitation order: [Do-not-resuscitate order written, confirmed, or not written] Goals-of-care designation: [The designation recorded, where your organization uses one] Old documents: [Replaced or voided, or none] Copies to: [Patient, decision-maker, hospital, specialists, care home, and where the original is kept] PLAN Next steps: [Forms to finish, people to talk to, and referrals such as palliative care] Review: [Date, or after a change in health, a hospital stay, or a new diagnosis] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Primary care, a visit booked for the conversation, with his daughter, 40 minutes
71-year-old man with heart failure, seen with his daughter, 2:10 to 2:50 p.m., face to face. Why now: 2 hospital stays for fluid buildup since June, and at his last visit he asked, “What happens if this gets worse?” He wanted his daughter in the room and agreed she could hear everything.
Has capacity for these decisions. He explained his heart condition and each choice in his own words, weighed what each would mean for him, and gave the same answers when asked again at the end. Hearing aids in; no interpreter needed.
“My heart is wearing out, and the water keeps coming back.” Knows heart failure doesn’t go away; wanted the full picture. Shared: his heart pumps weakly, with an ejection fraction of 30% on the August echo, and he is breathless after one block. Medicines ease symptoms and slow it, but more hospital stays are likely, and his time may be shorter than he hopes; no one can give a date. Quiet for a while, then said he was glad to talk about it.
Living at home with his wife, his vegetable garden, and Sunday dinners with his grandchildren. Biggest fear: “ending up on machines,” as his brother did, who spent 3 weeks on a breathing machine before he died. Would go to hospital for IV medicines, tests, and a few days of a breathing mask if he could get back home. Would not want to live unable to know his family, or depend on a machine to stay alive. Catholic; wants a priest called if he is dying.
Health care agent: his daughter, who lives 10 minutes away. Alternate: his son, who lives in another city. His wife has Parkinson’s disease and would usually be asked first; he wants his daughter instead, so his wife doesn’t carry it alone, and his wife agrees. His daughter knows his wishes and accepted the role. Leeway: “Follow what I said, but if the doctors think I can get home, she can decide.”
No CPR if his heart stops: he heard that CPR often fails when the heart is this weak, and that people who survive it often leave hospital weaker than before. Hospital care: yes, as a time-limited trial for problems that could be treated, including IV medicines and a breathing mask; if he isn’t improving after a few days, move to comfort-focused care. No breathing tube or long-term breathing machine. No feeding tube. He declined an implanted defibrillator last year and confirms that choice today. Overall: selective treatment, no CPR. I recommended this plan as the best fit for what matters to him.
Advance directive completed and signed today, with witnesses as the form requires, naming his daughter, then his son. Portable medical order completed and signed by him and me: no CPR; selective treatment; no feeding tube. Original on his fridge, where paramedics look. Copies to his daughter, his chart, his cardiologist, and the local hospital’s record, with his consent.
Offered a referral to the community palliative care team for breathlessness and support at home; he will think about it and tell his daughter. Review at his heart failure visit in 6 weeks, after any hospital stay, or sooner if he changes his mind. Told him he can change any of this at any time.
Hospital medicine ward, family meeting on day 3 of the stay, 50 minutes
86-year-old woman with Alzheimer’s dementia for 9 years, in a care home for 3 years, admitted with pneumonia from food and drink going down the wrong way, her second in 3 months. Present: her son, who is her named decision-maker; her daughter; the ward nurse; the social worker; and me, the attending physician. Her granddaughter joined by video. Meeting in a quiet room on the ward.
Lacks capacity for these decisions. Seen at the bedside before the meeting: awake, smiled at her son, said single words, and could not take in or weigh the choices. Decisions made with her son as her decision-maker, based on what she would want.
Son: “Mom has been fading for a year.” Her daughter hoped the antibiotics would fix it, and asked about a feeding tube. Shared: before this stay she needed help with all care, used a wheelchair, ate puréed food with help, no longer knew her children most days, and had lost 6 kg in 6 months. Day 3 of IV antibiotics, still on 3 L of oxygen. The speech-language pathologist found her swallow unsafe even with thickened fluids. Her dementia is in its last stage, and the pneumonia is likely to come back. A feeding tube would not stop it, as saliva still goes down the wrong way, and it doesn’t help people live longer or more comfortably at this stage. Her daughter cried, then said, “I don’t want her to suffer.”
In her advance directive from 2019, written while she could still decide, she said she would not want machines or tubes to keep her alive if she no longer knew her family. Her son recalls her saying after her husband died, “Don’t let them keep me going like that.” What matters to her now, in her family’s words: comfort, her own room at the care home, her music, and not being alone. Greek Orthodox; the family would like a priest to visit.
Her son, named in her 2019 advance directive; her daughter is the alternate. Both agreed with the decision below, and her granddaughter supported it. I reminded them the question is what she would choose, and that the team shares the weight of the decision.
I recommended comfort-focused care, and her son agreed on her behalf. No CPR. No intensive care or breathing machine. Stop the IV line, antibiotics, and blood tests. Oxygen and medicine for breathlessness or pain as needed. Careful hand feeding of foods she enjoys, for pleasure, accepting the risk of coughing or another pneumonia. No feeding tube. No transfer back to hospital for future infections; treat them at the care home for comfort.
Hospital resuscitation order changed from full code to do-not-resuscitate. Goals-of-care designation changed to comfort care on her chart. Portable medical order completed for the care home: no CPR, comfort-focused treatment, no feeding tube; signed by me and her son. Copies to the care home, her family physician, and the hospice team.
Back to her care home tomorrow, as her family wishes, with a hospice referral. Told the family what to expect: more sleep, less eating and drinking, and changes in her breathing. Chaplain visited today; her priest contacted. Care home nurse briefed by phone. Social worker to call her son on Friday. Revisit if her family’s view changes.
Each state and province names its documents and orders differently. These sources show what the main documents are and what a record must show; check the rules where you practice.
Who was in the conversation, what prompted it, and what the patient agreed others could hear.
Avoid: Leaving out who was in the room. Later readers need to know whether the decision-maker heard the patient’s wishes first-hand.
Whether the patient could make these decisions at the time, and, if not, who spoke for them.
Avoid: Assuming a dementia diagnosis means no capacity. Judge each decision at the time, and write what the patient could understand and weigh.
What the patient knows about their illness, what they want to know, and what you shared.
Avoid: Writing “prognosis discussed.” Record what you said about the likely course, and what the patient took from it.
The values behind every later choice. When a decision comes up that no form covers, this is the part people read.
Avoid: Skipping straight to procedures. Without the values, a “no CPR” box can’t guide the many decisions it doesn’t cover.
Who decides if the patient can’t, how that person was named, and whether they are ready for it.
Avoid: A name with no phone number, or a decision-maker who doesn’t know they were chosen.
The specific treatments discussed, each tied to what matters most, with your recommendation.
Avoid: Recording choices without reasons. “No breathing tube, because his brother spent 3 weeks on one” guides the next team far better than a checkbox.
The forms completed or changed, who has copies, and when to look at it again.
Avoid: Forms that never leave one chart. Paramedics, the hospital, and the care home need the same version.
“DNR signed” tells the next clinician nothing about why. Record what matters to the patient and the reasons behind each choice, so decisions the form doesn’t cover can still follow their wishes.
Asking “Do you want CPR?” before you know the patient’s goals invites a guess. Ask what matters most first, link each treatment to it, and give your recommendation.
Naming someone is half the job. Record whether they know they were named, agreed to it, and heard the patient’s wishes, ideally in the room.
When wishes change, replace or void the old order and directive, and say so in the note, so two versions don’t conflict in an emergency.
A form in a clinic record doesn’t help paramedics at 3 a.m. Record who got copies and where the original is kept, and send the update to the hospital and the care home.
Vero Scribe writes the advance care planning note in your template from the conversation, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
A conversation, often more than one, about the care a person would want if they became seriously ill or couldn’t speak for themselves: what matters most to them, who would decide for them, and which treatments fit their goals. It can lead to legal documents, such as an advance directive, and to medical orders, such as a POLST form or a do-not-resuscitate order. This note records the conversation.
Record who took part and why now; the patient’s capacity; what they understand about their illness; what matters most, including fears and trade-offs; the decision-maker; each treatment preference with its reason; the documents completed and who got copies; and when to review. Quote the patient’s own words where they explain a choice.
Advance care planning looks ahead, often while the person is well or stable, and settles values and a decision-maker. A goals-of-care conversation happens once serious illness is here, and turns those values into decisions about treatment now, such as intensive care, CPR, or a move to comfort-focused care. The same template works for both; the dementia example above is a goals-of-care meeting.
No. An advance directive is the patient’s own legal document, naming a decision-maker and giving wishes. A portable medical order, such as a POLST or MOLST form, is signed by a clinician and tells paramedics and hospitals what to do now. The note records the conversation behind them: who was there, what the patient said, and the reasons.
Any adult can, and it matters most for people with a serious illness, frailty, early dementia, or major surgery ahead. Portable medical orders are for people who are seriously ill or frail, not for healthy adults; for them, naming a decision-maker and sharing their values is enough.
Talk with their decision-maker: the person they named, or the person next in the default order where you practice. Ask what the patient would want, from their past words, documents, and values, not what the family would choose for themselves. Record the patient’s past wishes, who decided, and why, as in the dementia example.
It’s good practice. Some places pay for advance care planning as a timed service; where yours does, write the start and end times or total minutes, who took part, and that the patient or decision-maker agreed to the conversation, and check what counts toward the time.
When health changes: a new serious diagnosis, a hospital stay, a decline in function, a move to a care home, or when the patient asks. Many clinicians also revisit it once a year. Each review gets its own note, saying what changed and which documents were replaced.
Yes. Copy it, or download it as a Word or text file. No account needed.
Yes. Vero Scribe drafts the note in your template from the conversation, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF.
The SOAP note reordered: assessment and plan on top, with the history and findings below to back them.
For clinical phone calls and nurse triage: the caller, red flags, advice, disposition, and who calls back.
The chart note for a refill or renewal between visits: last fill, monitoring due, safety checks, the decision, and who approved it.
Your chart note on a lab or imaging result: the value and trend, urgency, action, patient contact, and tracking.
The record of a team or family care conference: attendance, consent, each discipline’s update, decisions, and actions with owners and dates.
Serious illness conversations documented, with patient priorities kept in view.
Home visits, after-hours calls, and team updates, drafted for your review.
Complex visits, caregiver guidance, and care plans for older adults.
Goals, medicines, and follow-up for long-term conditions, with advance care planning as one part.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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