Discussion and documentation of goals of care

Measure purpose: Engage patients in treatment planning

The numerator: Patients with a primary neurologic condition that are admitted to the intensive care unit (ICU) who have documentation of goals of care discussion with patient or patient surrogate.

is divided by

The denominator: Any patient with a primary neurologic condition admitted to the ICU

Exclusions are removed from the denominator for:

• Elective admissions into the hospital
• Patients who are unable to verbalize or discuss the issue who have no surrogate decision maker

Key Phrases

Key phrases you should document to meet the measure:

• Documented goals of care
• Discussed goals of care

Measure Calculation Example

Dr. Jones has 100 patients admitted to the intensive care unit (ICU) between January 1 and December 31 of the measurement year. Nine patients electively admitted themselves to the hospital and three patients were unable to discuss goals of care and did not have a surrogate decision maker present.

Of the 88 remaining patients, 29 of them had documentation that goals of care were discussed with either the patient or the surrogate decision maker.

Quality of care = 29/(100-12). Dr. Jones has a score of 33% for this measure.