Polst Printable Form PDF Details

The Physician Orders for Life-Sustaining Treatment (POLST) form represents a pivotal tool in healthcare planning, enabling individuals to outline their preferences for medical treatment in scenarios where they are unable to communicate their wishes. Effective as of October 1, 2014, and sanctioned by HIPAA for disclosure to necessary healthcare providers, the POLST form serves as a legally valid physician order once signed. It uniquely complements an Advance Directive by addressing immediate medical actions in life-sustaining scenarios, such as cardiopulmonary resuscitation (CPR) and varying levels of medical intervention, but does not replace the directive. With sections detailing the scope of treatment from full intervention to comfort-focused care, and stipulations on artificial nutrition, the POLST ensures that a patient's treatment preferences are respected across healthcare settings. Moreover, it necessitates discussions with the patient or a legally recognized decision-maker to ascertain consistency with the patient’s medical condition and preferences, making the form a critical communication bridge among patients, their families, and healthcare providers. The form's design—requiring signature validation by both the physician and the patient or decision-maker—underscores the importance of informed consent in medical decision-making. Given its legal validity, including in situations involving patient transfer or discharge, the document's significance in patient-centered care and ethical medical practice is profound.

QuestionAnswer
Form NamePolst Printable Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesorders polst online, emsa 111, printable polst form california, polst pdf

Form Preview Example

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:

 

 

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

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.

 

 

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,

 

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.

 

 

o Long-term artiicial nutrition, including feeding tubes.

Additional Orders:

 

CheckOne

 

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

How to Edit Polst Printable Form Online for Free

Our finest software engineers have worked together to develop the PDF editor that one could go with. This specific software makes it simple to obtain polst form documents shortly and without problems. This is certainly everything you should undertake.

Step 1: Press the "Get Form Now" button to begin the process.

Step 2: You can find all the options that you can take on the document when you have entered the polst form editing page.

These particular areas are what you will have to create to get the finished PDF form.

step 1 to filling in printable polst form

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.

Completing printable polst form stage 2

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.

Finishing printable polst form part 4

Step 3: Hit the "Done" button. Now you may upload your PDF file to your electronic device. Aside from that, you'll be able to forward it through email.

Step 4: Attempt to generate as many copies of your form as you can to stay away from potential problems.

Watch Polst Printable Form Video Instruction

Polst Printable Form isn’t the one you’re looking for?

Related Documents

  • Printable Daycare Form

    "... Users michael Desktop Forms Daycare Forms Doc 2009 Page of Westbrook Christian School 100 Westminster Drive Rainbow City Al 35906 256 442 7457www westbrookchristian.org Child Name Parent Name Child goes by Male Female Circle One ..."

  • Kwl Chart Printable

    "... This is an extremely useful tool and can be used in all content areas. However, it is important to not put the KWL charts before your students. For example, if you have a lesson about ..."

  • Menu Template Printable

    "... li censure Bureau child care licensing Child care Menu Form Child Care Provider Name & Pv Number if available Day Date Monday Tuesday Wednesday Thursday Friday Breakfast must contain fluid milk, fruit vegetables bread grains ..."

  • Piggly Wiggly Printable Application

    "... Inc. 2400 Terrell Woo Ten Drive Bessemer, Al 35020. Application for Employment Personal Please print clearly. Pre-existing mental or physical conditions can void the date of your application. Street address and street state zip codes ..."

Please rate Polst Printable Form

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .