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Question	Answer
Form Name	Polst Printable Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	orders polst online, emsa 111, printable polst form california, polst pdf

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HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTHCARE PROVIDERS AS NECESSARY

EMSA #111 B

(Effective 10/1/2014)*

Physician Orders for Life-Sustaining Treatment (POLST)

First follow these orders, then contact physician.	Patient Last Name:	Date Form Prepared:
First follow these orders, then contact physician.
A copy of the signed POLST form is a legally valid
A copy of the signed POLST form is a legally valid	Patient First Name:	Patient Date of Birth:
physician order. Any section not completed implies	Patient First Name:	Patient Date of Birth:
full treatment for that section. POLST complements
an Advance Directive and is not intended to	Patient Middle Name:	Medical Record #: (optional)
replace that document.

A	CARDIOPULMONARY RESUSCITATION (CPR):		If patient has no pulse and is not breathing.
		If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.
CheckOne	oAttempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B)
	oDo Not Attempt Resuscitation/DNR (Allow Natural Death)
B	MEDICAL INTERVENTIONS:		If patient is found with a pulse and/or is breathing.
B	oFull Treatment – primary goal of prolonging life by all medically effective means.
Check
One	In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation,
One	advanced airway interventions, mechanical ventilation, and cardioversion as indicated.

	oTrial Period of Full Treatment.
	oSelective Treatment – goal of treating medical conditions while avoiding burdensome measures.
	In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV
	luids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care.
	oRequest transfer to hospital only if comfort needs cannot be met in current location.
	oComfort-Focused Treatment – primary goal of maximizing comfort.
	Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment
	of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort
	goal. Request transfer to hospital only if comfort needs cannot be met in current location.
	Additional Orders:


C	ARTIFICIALLY ADMINISTERED NUTRITION:		Offer food by mouth if feasible and desired.
C	o Long-term artiicial nutrition, including feeding tubes.		Additional Orders:
CheckOne	o Long-term artiicial nutrition, including feeding tubes.		Additional Orders:
	o Trial period of artiicial nutrition, including feeding tubes.

oNo artiicial means of nutrition, including feeding tubes.

DINFORMATION AND SIGNATURES:


Discussed with:		o Patient (Patient Has Capacity)	o Legally Recognized Decisionmaker

o Advance Directive dated ________, available and reviewed à			Healthcare Agent if named in Advance Directive:
o	Advance Directive not available		Name:
o	No Advance Directive		Phone:

Signature of Physician

My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s medical condition and preferences.

Print Physician Name:	Physician Phone Number:	Physician License Number:

Physician Signature: (required)		Date:

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 patient who is the subject of the form.

Print Name:		Relationship: (write self if patient)

Signature: (required)		Date:

Mailing Address (street/city/state/zip):	Phone Number:	Ofice Use Only:

SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED

*Form versions with effective dates of 1/1/2009 or 4/1/2011 are also valid

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTHCARE PROVIDERS AS NECESSARY

Patient Information

Name (last, irst, middle):

Date of Birth:

Gender:

M F

Healthcare Provider Assisting with Form Preparation

o N/A if POLST is completed by signing physician

Name:

Title:

Phone Number:

Additional Contact

o None

Name:

Relationship to Patient:

Phone Number:

Directions for Healthcare Provider

Completing POLST

•Completing a POLST form is voluntary. California law requires that a POLST form be followed by healthcare providers, and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by a physician who will issue appropriate orders that are consistent with the patient’s preferences.

•POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conlicts.

•POLST must be completed by a healthcare provider based on patient preferences and medical indications.

•A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, or person whom the patient’s physician believes best knows what is in the patient’s best interest and will make decisions in accordance with the patient’s expressed wishes and values to the extent known.

•A legally recognized decisionmaker may execute the POLST form only if the patient lacks capacity or has designated that the decisionmaker’s authority is effective immediately.

•POLST must be signed by a physician and the patient or decisionmaker to be valid. Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy.

•If a translated form is used with patient or decisionmaker, attach it to the signed English POLST form.

•Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. A copy should be retained in patient’s medical record, on Ultra Pink paper when possible.

Using POLST

•Any incomplete section of POLST implies full treatment for that section.

Section A:

•If found pulseless and not breathing, no deibrillator (including automated external deibrillators) or chest compressions should be used on a patient who has chosen “Do Not Attempt Resuscitation.”

Section B:

•When comfort cannot be achieved in the current setting, the patient, including someone with “Comfort-Focused Treatment,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).

•Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations.

•IV antibiotics and hydration generally are not “Comfort-Focused Treatment.”

•Treatment of dehydration prolongs life. If a patient desires IV luids, indicate “Selective Treatment” or “Full Treatment.”

•Depending on local EMS protocol, “Additional Orders” written in Section B may not be implemented by EMS personnel.

Reviewing POLST

It is recommended that POLST be reviewed periodically. Review is recommended when:

•The patient is transferred from one care setting or care level to another, or

•There is a substantial change in the patient’s health status, or

•The patient’s treatment preferences change.

Modifying and Voiding POLST

•A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D, writing “VOID” in large letters, and signing and dating this line.

•A legally recognized decisionmaker may request to modify the orders, in collaboration with the physician, based on the known desires of the patient or, if unknown, the patient’s best interests.

This form is approved by the California Emergency Medical Services Authority in cooperation with the statewide POLST Task Force.

For more information or a copy of the form, visit www.caPOLST.org.

SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED

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You have to type in the necessary information in the Check One, artIfICIally admInIStered, Additional Orders, Offer food by mouth if feasible, D InformatIon and SIgnatureS, Discussed with o Patient Patient, o Advance Directive dated, Healthcare Agent if named in, Signature of Physician My, Print Physician Name, Physician Phone Number, Physician License Number, Physician Signature required, Date, and Signature of Patient or Legally field.

You can be requested to provide the details to help the platform fill in the box Signature required, Date, Mailing Address streetcitystatezip, Phone Number, Ofice Use Only, SEND FORM WITH PATIENT WHENEVER, and Form versions with effective dates.

printable polst form Signature required, Date, Mailing Address streetcitystatezip, Phone Number, Ofice Use Only, SEND FORM WITH PATIENT WHENEVER, and Form versions with effective dates blanks to complete

Make sure you specify the rights and obligations of the parties in the Patient Information Name last irst, Date of Birth, Gender M F, Healthcare Provider Assisting with, Phone Number, Title, Additional Contact o None Name, Relationship to Patient, Phone Number, Directions for Healthcare Provider, Completing POLST Completing a, providers and provides immunity to, POLST does not replace the, ensure consistency and update, and POLST must be completed by a part.

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