What template should I use for shared decision making in clinic or hospital notes?

Shared Decision Making Template for Clinical Documentation

The most effective shared decision making (SDM) template should include three core elements: information exchange, deliberation, and treatment decision documentation to ensure optimal patient outcomes and quality of life. 1

Core Components of SDM Documentation Template

1. Patient Information and Context

• Document the clinical situation requiring shared decision making, including diagnosis, prognosis, and reason for the preference-sensitive decision 1
• Note the patient's capacity to participate in decision making and identify surrogate decision-makers if applicable 1
• Record who was present during the SDM discussion (patient, family members, other healthcare team members) 1

2. Information Exchange Section

• Document the medical information shared with the patient, including:
  • Clear explanation of the diagnosis and current clinical situation using simple language 1
  • Description of treatment options presented, including risks, benefits, and alternatives 1
  • Prognosis information shared, including both mortality risk and functional outcomes 1
  • Documentation that the option of palliative care or conservative management was discussed (when applicable) 1
• Record how information was presented:
  • Note any decision aids, visual materials, or educational resources provided 1
  • Document the "chunk and check" approach used to ensure patient understanding 1

3. Patient Values and Preferences Section

• Document the patient's expressed values, goals, and preferences relevant to the decision 1
• Record any previously expressed treatment preferences (written or verbal) 1
• Note the patient's questions, concerns, and fears related to the options 1
• Document the patient's understanding of their condition in their own words 1

4. Deliberation Process

• Record the discussion of advantages and disadvantages of various options 1
• Document how the patient's values and preferences were incorporated into the deliberation 1
• Note any misperceptions that were addressed during the discussion 1
• Document the patient's preferred level of involvement in the decision-making process 1

5. Decision and Plan

• Clearly state the decision that was reached 1
• Document the rationale for the decision, linking it to the patient's expressed values 1
• Note any contingency plans or circumstances under which the decision would be revisited 1
• Record follow-up plans and timeline for reassessment 1

6. Attestation Statement

• Include a statement affirming that SDM occurred: "The above decision was made through a shared decision-making process in which the patient was informed of the options, risks, benefits, and alternatives, expressed their values and preferences, and actively participated in reaching this decision." 1
• Document that the patient had the opportunity to ask questions and that these were addressed 1

Implementation Tips

• Tailor the template to the specific clinical context while maintaining the core elements 1
• Use patient-friendly language in your documentation that reflects the actual conversation 2
• Document time spent in shared decision making to support appropriate billing 1
• Integrate the template into your electronic health record system for ease of use 1
• Consider using standardized phrases for common SDM scenarios in your practice 3

Common Pitfalls to Avoid

• Avoid documenting SDM when it did not actually occur - this template should reflect a genuine process, not just a checkbox 4
• Don't use overly technical language that doesn't reflect the actual conversation with the patient 1
• Ensure documentation reflects the patient's actual level of participation rather than assuming full engagement 1
• Avoid focusing solely on risks and benefits without documenting how the patient's values influenced the decision 5
• Don't rush through documentation - inadequate SDM documentation may have legal implications if adverse outcomes occur 6

By implementing this comprehensive SDM template, you'll not only improve documentation but also enhance the quality of your decision-making process with patients, leading to better alignment with patient values and improved health outcomes 1, 4.