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Form · HSP-FRM-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 10 (Hospice and Palliative Care), criterion 10.3
Purpose
Records the patient’s goals, values and wishes, including advance directives, and when they were reviewed.
How to complete
- Ask the patient directly, and record their words.
- Record any advance directive and where it is kept.
- Review as the illness changes.
Checks
| Check | Entry |
|---|---|
| Goals and what matters most to the patient | Yes |
| Preferred place of care | Yes |
| Advance directive held (yes or no) and location | Yes |
| Substitute decision maker named (if any) | Yes or N/A |
| Reviewed on (date and reason) | Yes |
| Recorded by and date | Yes |
Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Palliative Care fact sheet and the Lancet Commission on the Global Access to Palliative Care and Pain Relief (2017). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)