An Interim Goals of Care Designation (GCD) order means a preliminary documented medical order for the goals of care designation placed by the most responsible health practitioner (MRHP) until a more fulsome Advance Care Planning (ACP) conversation can take place between the patient, designated family / support person(s) as appropriate, and the MRHP. Interim GCD orders are meant to be used in circumstances where documentation of the care approach is needed, but a conversation with the patient and/or an alternate decision maker is not possible. This may be either due to patient health factors (see examples below) or circumstances that would make the timing of the conversations inappropriate, such as a non-urgent overnight admission where GCD can be discussed in the morning and/or unclear ACP GCD documentation that requires further discussion. It's important to note that an interim GCD order is not intended to be used as a tool to avoid or indefinitely defer ACP GCD conversations. An interim GCD order may be used to describe any care approach (R, M or C).

Examples of patient health factors include, but are not limited to:

• Head injury with altered level of consciousness
• Delirium
• Capacity concerns
• The patient wishes to defer the conversation until their designated family/support person is available

A checkbox, located on the paper form and within the Connect Care order window, will be selected indicating the GCD order is considered an interim order. This means the GCD needs to be re-evaluated as soon as clinically appropriate and updated to a standard GCD order during the course of clinical care. Rationale for using an interim GCD order should be documented and, ideally, include an anticipated time frame for updating.

While there is no specific timeline, an interim GCD order should be re-evaluated and updated to a standard GCD order as soon as clinically appropriate. Ideally an interim GCD order is re-evaluated within hours (e.g. patient admitted overnight and is sleeping, delay conversation until the next day) or days. It's also important to review GCD orders as part of care transitions, such as a discharge or transfer to a continuing care home setting, to ensure that any interim GCD orders are updated to a standard GCD order before the patient is transitioned. In some circumstances an interim GCD order could be in place longer, such as if the interim GCD order awaits the outcome of a dispute resolution process.

Surgery or a specific procedure: No, this would not be considered an appropriate use of an interim order, as a conversation with the patient should take place prior to the procedure. Note that discussing the risks and goals of surgery, and confirming the GCD with the patient (e.g. R1 approach), equates to a GCD conversation — so a standard GCD order should be used, not an interim one. If the patient expresses specific wishes in relation to their surgery, this can be included in the "clarifications" section of the GCD order.

Disagreement about the approach to care: It depends. In complex decision-making situations, supports such as second opinions, clinical ethics consultation, spiritual care involvement, palliative care consultation, and health law/legal consultation can be used before a formal dispute resolution process is initiated. These supports may help navigate options without using an interim GCD order or escalating to a formal dispute. If disagreements persist despite using decision-making resources, then it may be appropriate to escalate using the dispute resolution process in the AHS Dispute Prevention and Resolution in Clinical Settings Policy. Once a dispute resolution process has been initiated, it is appropriate to consult with health law and/or clinical ethics about whether an interim GCD order is applicable.

Where an interim order awaits the outcome of a dispute, separate checkboxes on the paper form and within the Connect Care order window indicate this. Relevant information should be documented in the patient's chart and Tracking Record.

All patients and persons in health care should be given the opportunity to participate in an ACP discussion — all adults can benefit, as any of us may have an unexpected event or change in health. These discussions can be initiated by the primary care physician as part of routine health care, but also by patients or other health care professionals, and can occur in all health care settings. They allow for respectful understanding of wishes concerning care and specific interventions, and include communication among health care professionals, patients, and, when appropriate, alternate decision-makers.

These conversations explore the goals for treatment and the patient's wishes framed within the therapeutic options that are appropriate for the patient's current clinical condition, and those which may be relevant for the patient's future clinical conditions. They incorporate the values and wishes of the patient as well as guide interventions. These conversations should ultimately lead to the most responsible health care professional writing an appropriate GCD order.

Conversations are best started early in the patient's course of care and/or treatment and/or when clinically appropriate to the patient's care. Conversations and decisions about GCD are carried out with the patient or with the patient's alternate decision-maker if the patient lacks capacity to make such decisions. Particularly important times to engage include:

• During an admission to a hospital or care facility
• Before surgery
• When a patient is transferred from one health care facility to another
• When a patient attends an emergency department or urgent care centre
• During an annual check-up with the family doctor
• Any time there is a change in patients' health circumstances; and/or
• At patient's discretion, e.g. whenever they are preparing or reviewing their advance care plan.

Every clinical situation is unique; however, the following questions offer a non-threatening way to ask about ACP/GCD.

• A question we ask all of our patients is about current and future health care decision making. Have you heard about Advance Care Planning? Do you have a personal directive?
• It is important for the health care team to know your wishes if you were seriously ill and could not make decisions for yourself. Have you talked with anyone about your wishes or preferences for health care decisions that may come up (e.g. resuscitation)? May I ask what you discussed?
• Knowing more about you will help us get the treatments that are best for you. What is important to you when you think about health and the future?
• Explore discussions with family, agent or health care providers.
• These questions lead to natural exploration of wishes, or may help you be aware if the patient has appointed an alternate decision maker (ADM) or agent.
• Who can initiate and conduct these conversations?

A patient can ask to have this conversation. Any member of the patient's health care team (for example; MD, RN, RRT, LPN, OT, SW,) can initiate the conversation and conduct appropriate parts of the Advance Care Planning discussion. A physician or nurse practitioner is ultimately responsible to ensure the most clinically appropriate Goals of Care Designation Order is in place.

The conversations may include:

• A patient's understanding of the illness, prognosis and the anticipated outcomes of current treatment.
• Exploration of the patient's values, understanding, hopes, wishes and expected outcomes of treatment.
• The role of life support interventions and/or life sustaining measures and their expected degree of benefit.
• Preferred locations of care (home, facility living, hospital)
• Information about comfort measures.

If appropriate, offer for involvement of resources such as palliative care, social work, clinical ethics consultation, or spiritual care to assist the patient with their needs.

• patients admitted to a hospital or care facility,
• patients who are seriously ill and receiving medical or home care support,
• patients who want to discuss their values and beliefs, health condition and determine treatments options

The MRHP is the physician or nurse practitioner who is overseeing the course of care for a patient. The formal policy definition: the health practitioner who has responsibility and accountability for the specific treatment/procedure(s) provided to a patient and who is authorized by Alberta Health Services to perform the duties required to fulfill the delivery of such a treatment/procedure(s) within the scope of his/her practice. Currently in Alberta, to provide medical orders, the MRHP is usually a physician. In some circumstances, a Nurse Practitioner is the MRHP. The definition is deliberately broad, to allow the flexibility to adapt to a change of clinical leadership or responsibility in any situation.

Determining and writing a GCD Order is a cooperative activity involving the patient and whichever care providers are best placed to undertake these conversations. Often, the family physician is that care provider. As new information is understood from specialist consultants participating in the patient's care, alterations to the Order may be required, and can be written by the consultant or the family physician. Examples where the specialist might be best equipped to write the order include:

• Dialysis patients seen regularly by the nephrologist: the nephrologist should address the plan of care and write the GCD order.
• Patients with cancer undergoing active or palliative treatment at a cancer centre: the oncologist or palliative care physician at that centre should address the plan of care and write the GCD order.
• Patients undergoing surgery: the surgeon would be responsible to address the plan of care relevant to this "episode" of care and write the GCD order.
• Patients discharged without a family physician relationship, or whose family physician does not know their current health status: the physician or nurse practitioner should address the plan of care and write the GCD order.

If a patient's MRHP changes, the previous Goals of Care Designation order remains applicable unless changed by the new MRHP. It should be reviewed with the patient by the new MRHP.

Goals of Care Designations should be reviewed when new circumstances or health issues arise, when a patient is transferred to a new location of care or if the patient or alternate decision-maker requests it. A Goals of Care Designations order is prescriptive – it guides the clinical team regarding the course of care and interventions - but is also subject to clinical judgement of the current most responsible health practitioner. If the current GCD no longer makes clinical sense or seems to be in conflict with the patient's wishes, it should be reviewed and can be changed if necessary.

The ACP GCD Procedure (2.1) states that GCD orders are reviewed when clinically appropriate. Some services and programs develop internal review processes as "best practice" — for example, in many continuing care facilities residents have an annual care plan review, and at this time their GCD is updated.

Informed consent and patient signature are not required to make a Goals of Care Designation order because it is a medical order. As a medical order, it is the clinical responsibility of the most responsible health practitioner. It is standard clinical practice to engage the patient or alternate decision maker in all related discussions and decisions so their wishes are known and considered. A patient or ADM signature is not required for documentation.

Original GCD order forms are recommended as one source of truth, however if a health care provider must make a copy of the original Goals of Care Designation Order for any purpose, the health care provider should add a notation to the copy stating "true copy of the current Goals of Care Designation order for this patient" with the staff member's signature, date and printed name. Retaining a photocopy on the chart is needed when a patient attends outpatient care at the same location regularly (e.g. dialysis, chemotherapy), or when a resident goes on a day recreational outing and carrying their Green Sleeve is not feasible.

There is a paper version of a GCD Order, stored in the patient's Green Sleeve except in areas that use electronic order entry. In areas using an electronic health record the GCD order is entered and viewed in electronic format. When a patient is transferred from an electronic entry site to a paper entry site (or to their home), the sending unit prints a paper copy and places it in the Green Sleeve. Both paper handwritten and electronically generated print forms are considered originals.

When there are multiple completed order forms (e.g. from transfers or changes to health status): the most current form should be at the front of the Green Sleeve. Outdated forms can be housed within the Green Sleeve but should be filed sequentially by date in descending order (most recent on top). A no-longer-current order should have "VOID" written on it prominently, along with the date, to reduce the chance of error.

While both a clear GCD order and Personal Directive are ideally completed prior to admission to a designated living option, they are not required prior to admission. If they have not been completed prior, this activity should be undertaken as soon as is reasonable after admission. If they have been completed prior to admission, the GCD Order should be reviewed upon admission to assure it still reflects an appropriate goal of care designation.

When circumstances bring significant complexities, including disagreement in what care is to be provided, additional decision support may be required. Examples of circumstances where dispute resolution may need to be initiated: refusal of treatment by the patient/ADM; demand for treatment not within standard of care; disagreement with the ADM regarding the patient's wishes, best interests, values or beliefs; clinician disagreement on what treatment is clinically indicated; or emergency circumstances where time-critical decisions contradict the ADM's information. The MRHP has a responsibility to ensure a patient is informed of, and has access to, the decision support and dispute resolution resources found in the ACP/GCD Procedure (paragraph 7 and Appendix C).

Patient refusal of specific clinically indicated intervention(s) shall be honoured, within the bounds of applicable laws. Further conversations regarding patient refusal may be required. Clinical judgment should determine the degree to which further conversations should be considered and whether or not a dispute resolution process should be invoked.

Unless the Personal Directive is enacted, the agent has no legal standing to provide direction on the GCD order — if the person is still considered to have capacity, they are the legal decision-maker for their care. However, an individual may defer decision-making to another person by choice, or include them in the discussions leading to a supported or joint decision. With capacity, that would be the individual's choice.

The original Tracking Record is kept in the Green Sleeve to allow care providers at each site access to and the ability to document the full record of conversations that have occurred over time. Having multiple versions/copies contributes to confusion and possible miscommunication. If a Tracking Record is full after multiple sequential conversations, begin a new one and keep the full prior record in the Green Sleeve, stapled behind the current record. When the patient is discharged or transferred, a copy is kept on the patient's chart.

Any health care professional or member of the health care team who documents in the chart can record information on this form. Patients and families don't write on this form.

When the patient is receiving care or is admitted, the Green Sleeve should be placed at the front of the patient's chart. The ACP/GCD documents and Green Sleeve are the property of the patient. On discharge from acute care, the unit clerk places a copy of the ACP/GCD documents on the health record and returns the originals in the Green Sleeve to the patient. If the original remains on the chart after discharge, the unit clerk calls the patient or facility; if unable to reach them, the Green Sleeve is sent to Health Records, who returns it to the patient by mail.

In certain circumstances a person may require a change in their GCD order. Where the MRHP is not on site and is only available by telephone, the RN may take a verbal telephone GCD order. In this urgent situation, the RN documents the verbal telephone order on the GCD order form, makes a checkmark within the relevant GCD order box, and places their initials in the relevant line below the selected GCD order. The MRHP must then co-initial on this line and sign the order at the earliest possible opportunity.

Clinical example: Mrs. Hill is a 78-year-old residing at home with advanced cancer, now bedbound and requiring 24-hour care. Her current GCD order is M2, reflecting her earlier desire to be cared for without transfer to hospital; she has now made clear she wishes to transfer to hospice for end-of-life care. Her home care nurse phones her FP, who provides a telephone order for a C1 GCD and will fax a new signed C1 GCD to the home care RN at the end of clinic.

Interventions by health care providers when a person is choking may start with abdominal thrusts and/or chest compressions depending on the situation. If attempts to alleviate the obstruction are not effective and the person becomes pulseless and breathless, the known GCD order will provide direction for further intervention and care, including whether CPR should be initiated. If chest compressions are used to alleviate an obstruction, they can be stopped when the obstruction is relieved or there is confirmation of ventilation (a breath is provided and the chest rises).

Some individuals state they would not want chest compressions if they choked, even if it results in death — for some, because chest compression may cause significant harm. Where individuals do not want chest compressions in this circumstance, documentation is required on the GCD order form under the specific clarifications section, and conversations recorded on the ACP Tracking Record. It is important to discuss this with persons at high risk of aspiration; in facility living, care teams are encouraged to have these conversations at the initial and annual care conferences. Examples of special circumstances: a person with extensive bone metastasis to the rib cage or sternum; a person with a known aspiration risk who wishes not to have chest compressions initiated; a person who has previously had chest compressions to alleviate choking and does not wish them repeated.

Yes — non-invasive ventilation such as BiPAP, CPAP, or High flow Heated Humidified Oxygen can be used in individuals with a non-R GCD Order if the intent of the treatment aligns with the GCD order. Non-invasive ventilation delivers mechanical ventilation without an endotracheal airway; it is used for life sustainment, life prolongation, and may be used to alleviate symptoms and/or suffering. Use is based on physician recommendations, the availability of resources (e.g. respiratory therapist and/or equipment), and the GCD order based on discussions with the person and their family/ADM.

Clinical examples:

• Life prolonging (appropriate for R GCDs) – individual admitted with pneumonia cannot maintain O2 saturations; BiPAP is utilized.
• Life sustaining (appropriate for M GCDs) – individual with IPF admitted with hypoxia; High flow Heated Humidified Oxygen improves oxygenation and manages dyspnea.
• Symptom control (appropriate for all GCDs) – individual with sleep apnea uses CPAP nightly, resulting in increased daytime alertness.

Yes – depending on site-specific practices, these teams can respond for patient deterioration and support the health care team and attending physician outside of the ICU. For example, a patient with an M1 GCD becomes seriously unwell with a sudden drop in blood pressure and reduced level of consciousness on an evening shift; the attending physician is on-call from home, 20 minutes away. A code 66 is called to provide rapid response while the attending travels in.

An AED lead placement may be used in patients with R1, R2 and R3 GCDs because it assists in diagnosing, especially during the time required to call a code team (assistance does not imply resuscitation).

• R1 – Full CPR, including the potential for an AED shock, can be used.
• R2 – In the rare circumstances that a shock alone will revive someone, it is reasonable to try an AED, recognizing that without full CPR chances of success are limited. A limited attempt (e.g. a shock) would usually comply with the R2 order and the patient's wishes, even if it fails.
• R3 – A person with an R3 order is not looking for resuscitation attempts for cardiorespiratory arrest. R3 allows for situations where a patient is already in a critical care area but would not want or benefit from chest compressions or ventilation; occasionally such patients could benefit from controlled cardioversion with electricity, drugs and dialysis in an ICU, where a malignant arrhythmia can be acted on quickly enough for a reasonable chance of survival without CPR. On a non-CCU/ICU unit or outpatient area, such a patient is most likely to survive only with all resuscitative measures; a shock, if available, can be tried but should not be repeatedly employed at risk to the dying patient's dignity.

Cardioversion is not always linked to chest compressions. The R3 GCD order was designed for patients in heart-monitored situations whose malignant rhythm disturbance might be correctable by electricity and/or cardiac drugs, but who have chosen not to receive chest compressions and mechanical ventilation. If such a person has a monitored rhythm disturbance requiring cardiac interventions, those are undertaken when required. If found pulseless, appropriate and limited cardiac interventions (electricity and/or cardiac drugs) can be undertaken, understanding the restriction against chest compressions might limit success. In an unmonitored situation, a pulseless person with an R3 order prohibiting chest compressions and mechanical ventilation has died, and it would be exceedingly unlikely to revive them with only electricity — though it would not be unreasonable for a code team or first responder to place leads, assess the rhythm and attempt electricity without going further. This is a clinical judgment call.

Advanced airway management, such as with a supraglottic airway (SGA) device and intubation, are considered life support measures usually used in critical care settings that provide ventilator support, and are appropriate for patients with an R1 or R2 GCD. Patients with other GCDs (R3, M and C) are not expected to benefit from and/or do not desire ventilation support. Basic airway support using oral pharyngeal and nasal pharyngeal airway devices can be appropriate for patients with any GCD when the intent is to temporarily support the airway and align with the patient's treatment goals.

Transfer to hospital may be considered when symptoms cannot be managed in the person's current care setting. With an M2 GCD, transfer can be considered if the patient agrees after an ACP/GCD conversation. With a C1 GCD, transfer should occur if symptoms can be better managed elsewhere and the patient agrees. With a C2 GCD, transfer should occur in rare circumstances, considering where it will be best for the patient to die and whether the care team is confident the patient is unlikely to die during transport.

Clinical example: Mr. Kumar is an 82-year-old residing in a facility with severe CHF, COPD and frailty. His current GCD order is M2; he has made clear he wishes his symptoms managed at his facility and does not wish to go to hospital. However, he trips and appears to have fractured his leg, with pain that cannot be managed at the facility. He is transferred to hospital for surgical repair.

Major surgery can be considered for patients with M1, M2 or C1 GCDs to fix a correctable problem or prevent suffering from an unexpected trauma or illness. The surgical and anesthetic teams require clarity on the use of resuscitative measures. Possible transfer to ICU for peri-operative complications or post-operative support should be discussed with the patient/ADM; ICU transfer may be considered for short-term physiological and mechanical support to return the patient to prior level of functioning. The possibility of intra-operative death should also be discussed.

Clinical example: Mr. White, 58, has multiple myeloma with extensive bone involvement and can no longer receive cancer-modulating therapies; his GCD order is C1. He slips on ice and sustains an unstable tri-malleolar fracture, and decides to proceed with operative repair. He is informed he may require a period of ICU observation post-operatively and agrees to a short-term stay if he will return to a previous level of functioning. The discussion is documented on the Tracking Record and on the GCD order under "specific clarifications." At surgery his GCD is reviewed as part of the safe surgical checklist; a new GCD does not need to be written as long as the surgical, post-op and anesthesia teams are aware of the special clarifications.

No patient is absolutely excluded from ICU care simply as a result of a previously determined GCD order. "In the moment" decision-making by the current care team may lead to revocation of a GCD order and potential ICU admission, if felt necessary and appropriate. In general, however, adult patients with M and C GCD orders are not candidates for ICU admission because they are not expected to benefit from, and are not desiring of, treatments provided in that environment. Considerations:

• Patients already in ICU sometimes have orders altered to palliation and withdrawal of life-sustaining interventions (to C1 or C2). A C2 patient would be expected to die in the ICU as a result of that change.
• Patients may require a short, defined period of post-operative ventilator support or monitoring in ICU as part of an emergency surgical intervention to manage symptoms or suffering. Characterizing the stay this way keeps it clear that if the short, goal-directed ICU stay is not achieving its goals, interventions can be discontinued after appropriate conversations. Ideally the patient/ADM would have been made aware of and agreed to this before the procedure.
• In pediatrics, patients are often admitted to ICU for end-of-life care because, outside of pediatric hospices, the ICU is often felt to be the place for ideal symptom management and preparation for death.

A GCD designation of M1 should not be the sole reason a patient is turned down for angioplasty (PCI). The M1 definition includes language allowing major surgery, resuscitation during surgery or recovery, and short-term physiologic and mechanical ICU support to return the patient to prior function, with the possibility of intra-operative death discussed in advance. Good conversation — considering functional status, risk/benefit and patient goals — determines suitability, and must include the risk of peri-procedural arrest and guidance on what, if anything, will be undertaken to resuscitate. M1 patients can receive resuscitation attempts, with advance agreement, with the limitation that an ICU stay or prolonged life-support dependence would not be considered; eventual withdrawal of life support, after appropriate conversations, would be ethically and legally permissible. Some patients direct that no resuscitation occur, and the cardiology team may be uncomfortable proceeding in that context.

For referrals requiring transfer (patients with capacity who are their own decision makers): it is essential the referring team document a patient-centred, clinically appropriate plan should a cardiac arrest occur during the procedure.

• First, the referring physician discusses potential risks and benefits with the patient (consulting cardiology if clarification of procedure risks is needed) and documents the patient's wishes on the GCD order Special Clarifications and Tracking Record. The current non-R1 GCD remains unchanged. If the patient directs that no resuscitation or intubation occur, this must be flagged and discussed with the cardiology team before booking and transport. Sample Special Clarifications charting: Risks and benefits of interventional cardiology procedure discussed with patient and their significant other. In the event of an arrest during the procedure the patient is agreeable to CPR being initiated, possible intubation, and is accepting of a short-term trial in ICU. The patient sees "short term" as meaning 30 days and does not wish their life to be sustained or prolonged by medical interventions beyond that period if the treatment team recommends withdrawal of care or feels care is not clinically appropriate, is potentially harmful, or is futile.
• Second, prior to transport the referring team communicates the GCD special clarifications to both the cardiology/interventional cardiology staff and the paramedic transport team. Before the procedure, the interventional cardiology physician describes the procedure and risks, addresses intubation and ICU, obtains informed consent, and reaffirms the patient's wishes and plan of care. That physician may decline to offer the procedure, in which case the referring physician considers alternate care.
• Third, post-procedure the patient's GCD order should be revisited, as the patient's values and goals may have changed, and reflected in a new order if needed.

Without a confirmed current GCD order, past orders must be interpreted with caution — they offer clues but cannot be assumed to be the patient's current order. On admission, the receiving team should always validate the presence of a GCD with the patient. If no known GCD exists, a new one should be ordered by the MRHP considering the patient's current clinical status, wishes and values. This is crucial because, in the absence of a known GCD order, the patient defers to receive R1 care; the patient/substitute decision maker should know this, which may expedite a conversation and updated order.

If the patient has capacity and can communicate: ask, "Our records show that in (month/year) M1 was written as your GCD order. Is this still the case?" Regardless of the response, involve the MRHP to write a new updated order. Start a new Green Sleeve with the new order — relying on the possible arrival of the home/facility Green Sleeve is not safe. Document the conversation on the Tracking Record. If the family/facility later brings the "home" Green Sleeve, organize the documents into one current Green Sleeve with the new order at the front.

If the patient lacks capacity or cannot communicate: share what prior information you know with the MRHP; determine if the patient has a Personal Directive naming an agent or substitute decision maker; assist in communicating with the substitute decision maker if known; the MRHP determines and writes the new order.

When friends and family take a resident out, they usually do not carry the GCD order. But residents in continuing care facilities commonly have complex health issues and greater risk of medical events. When participating in facility-organized off-site activities, AHS staff are responsible for carrying personal health information needed to maintain care (medications, emergency contacts, allergy information) including the GCD order, in case a resident experiences a critical health event. Carrying the Green Sleeve containing all advance care planning documents is best practice — in a medical event, all ACP/GCD documentation is necessary for EHS/EMS and acute care clinicians to understand the reasons for the current GCD order.

If the original GCD order cannot accompany the resident, a photocopy of the most recent order may be relied upon to guide treatment, provided it has a notation stating "true copy of the current Goals of Care Designation order for this patient" with the staff member's signature, date and printed name.

• Who prepares the photocopy? A regulated health care provider such as an RN or LPN who prepares other documentation (client list, medication administration records) should also prepare the Green Sleeve or GCD order. Follow local procedure.
• When might it be needed? Any event where EHS/EMS is called — e.g. a choking or airway event, a fall, a change in level of consciousness, or an allergic reaction.
• If the resident is transported to hospital, the Green Sleeve or GCD order should be given to EHS/EMS clinicians to accompany them.
• Documentation: follow local procedure including contacting the facility/unit. Document the event/circumstances, actions taken, and outcome (including whether the patient was transported), and that the Green Sleeve or GCD order was provided to EHS/EMS.
• Security: hold Green Sleeves or GCD orders in safekeeping with other confidential information in a secure but easily accessible location, treated like other confidential client information (e.g. medication administration records, allergies).
• If lost, stolen or damaged: follow the policy for loss of confidential information and report as a breach of privacy. Inform the care unit so the GCD order can be rewritten. Complete an online RLS report (for AHS staff) and any additional incident reports, and review the circumstances to reduce recurrence.

In the absence of a mobile printer/scanner, a health care professional can take a photo of ACP/GCD documents using their employer-issued AHS mobile device. Recommended guidelines:

• WThe photo must provide a clear, focused copy of the ACP/GCD documents without other items in the background.
• If the document has several pages, consolidate the photos into one file (e.g. a multi-page Tracking Record uploaded as a single file).
• Complete the appropriate charting to indicate a photo of ACP/GCD documents was uploaded into the patient's chart.
• After uploading to the AHS secure network, delete the image(s) from the employer-issued device.
• Ensure the most current GCD order and Tracking Record are returned to the client's Green Sleeve.

Yes. A GCD order generated from Connect Care, like all medical orders, is considered valid. When the phrase "signed electronically in Connect Care" is seen, it can be trusted just like a handwritten signature. The information is stored within Connect Care on a secured AHS server. If authenticity requires verification, anyone with access to Connect Care can view the document on the ACP/GCD navigator.