SHARED GOALS OF CARE WDHSL - Oamaru Hospital Question Title * 1. Patient's NHI Question Title * 2. Is there a shared goals of care form completed (for this admission)? Yes No Question Title * 3. Is the form easily located at the front of the file? Yes No Question Title * 4. Is the sticker with the patient's name and NHI on both sides of the form? Yes No Question Title * 5. What was the option chosen? Goal of care is Curative or Restorative - treatment aims to prolong life Goal of care is Curative or Restorative- treatment aims to prolong life and enhance quality Goal of care is improving quality of life Goal of care is comfort whilst dying Question Title * 6. Was the form signed and dated by Registrar or Consultant or Midwife? Yes No Only signed, not dated Only dated, not signed Question Title * 7. Is the box ticked that SMO has been informed of SGOC decision? Yes No Question Title * 8. Does the form document the discussion with the patient/whanau? Yes No Not on the form, but in the notes No discussion documented for not discussing documented on form (eg. dementia) Question Title * 9. Is there documentation of who was involved in the discussion? (Support person) Yes No Question Title * 10. Was the form signed by the patient or representative? Yes No Question Title * 11. The SGOC was completed and signed within: 0 - 24 hrs after admission 24.01 - 48 hrs after admission 48.01 - 72 hrs after admission Greater than 72 hrs after admission Question Title * 12. Does the patient have an advanced care plan? Is it noted on the form? Yes & noted on form Yes & not noted on form No & noted on form No & not noted on form Question Title * 13. Does the patient have an advanced directive? Is it noted on the form? Yes & noted on form Yes & not noted on form No & noted on form No & not noted on form Question Title * 14. Does the patient have an active enduring power of attorney? Is this acknowledged on the form? Yes & acknowledged on form Yes & not acknowledged on form No & acknowledged on form No & not acknowledged on form Question Title * 15. Escalation - Did the patient meet the criteria for escalation for CPR? Yes No Question Title * 16. Escalation Plan - Was the SGOC plan followed with regards to CPR? Yes No Done