Shared decision-making is a patient-centered conversation where the clinician and patient together map out the best course of action based on patient preferences as it relates to the clinical evidence. It is a process in which both the patient and the physician or non-physician practitioner such as a PA, NP, or clinical nurse specialist contribute to the medical decision-making process and agree on treatment decisions. This has shown to increase the knowledge and satisfaction regarding care, define clearer goals for treatment, and to align health decisions with patient values. When there is clear documentation in the medical record that a shared decision-making discussion occurred, then yes is coded for Sequence 14732, Shared Decision Making. Always work with your providers to determine a process of documentation that will allow for the coding of shared decision-making as this cannot be left to the interpretation of the abstractor or the ASC registry. A statement by the provider that a shared decision-making encounter occurred is sufficient for coding. The use of a shared decision-making tool would allow for the coding of this data element as well. Additionally, using a smart phrase within the facility's EHR system regarding shared decision-making is sufficient to code shared decision-making as yes in addition to easing the burden of documentation and data abstraction. It is important to note that shared decision-making and informed consent are not the same. It may be helpful to watch the informative video available by going to CardioSmart.org and selecting the video hyperlink.

shared decision-making

patient preferences

clinical evidence

medical records

informed consent