COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED
Patient’s Last Name
for Scope of Treatment (POST)
This is a Physician Order Sheet based on the medical conditions
and wishes of the person identified at right (“patient”). Any section
not completed indicates full treatment for that section. When need
occurs, first follow these orders, then contact physician.
First Name/Middle Initial
Date of Birth
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and/or is not breathing.
Do Not Attempt Resuscitate (DNR/no CPR)
When not in cardiopulmonary arrest, follow orders in B, C, and D.
MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.
Comfort Measures Treat with dignity and respect. Keep clean, warm, and dry.
Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen,
suction and manual treatment