HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY FOR TREATMENT
North Dakota POLST: Physician Orders for Life Sustaining Treatment
for Life-Sustaining Treatment (POLST)
Patient’s Last Name
FIRST follow these orders, THEN Call the appropriate medical contact.
These medical orders are based on the patient’s medical condition
Patient’s First Name/Middle Initial
and wishes. Any section not completed implies full treatment for that
section. Everyone shall be treated with dignity and respect.
Patient’s Date of Birth (mm/dd/yyyy)
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.
DNR/DO NOT ATTEMPT RESUSCITATION (Allow Natural Death)
When not in cardiopulmonary arrest, follow orders in B and C.
MEDICAL INTERVENTIONS: Patient has pulse and/or is breathing.
Comfort Measures always provided regardless of level of care chosen.
COMFORT MEASURES ONLY - Use me