HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Physician Orders for Life-Sustaining Treatment (POLST)
First follow these orders, then contact Physician/NP/PA. A copy of the signed POLST form is a legally valid physician order. Any section not completed implies full treatment for that section. POLST complements an Advance Directive and is not intended to replace that document.
Name
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First Name
Middle Name
Last Name
Date Form Prepered
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Month
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Day
Year
Date
Patient Date of Birth
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Month
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Day
Year
Date
Medical Record
CARDIOPULMONARY RESUSCITATION (CPR)
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Attempt Resuscitation/CPR
Do Not Attempt Resuscitation/DNR
MEDICAL INTERVENTIONS
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Full Treatment
Trial Period of Full Treatment
Selective Treatment
Request transfer to hospital only if comfort needs cannot be met in current location.
Comfort-Focused Treatment
Additional Orders
ARTIFICIALLY ADMINISTERED NUTRITION
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Long-term artificial nutrition, including feeding tubes
Trial period of artificial nutrition, including feeding tubes
No artificial means of nutrition, including feeding tubes
Additional Orders
INFORMATION AND SIGNATURES
Discussed with:
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Patient (Patient Has Capacity)
Legally Recognized Decisionmaker
Advance Directive
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Advance Directive dated
Advance Directive not available
No Advance Directive
Date
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Month
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Day
Year
Date
Health Care Agent if named in Advance Directive
Name
Phone Number
Please enter a valid phone number.
Signature of Patient or Legally Recognized Decisionmaker
I am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form.
Name
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First Name
Last Name
Signature
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Date
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
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