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, nurse practitioner
or PA-C. The POLST is a set of medical orders intended to guide
medical treatment based on a person’s current medical condition
and goals. Any section not completed implies full treatment for that
section. Completing a POLST form is always voluntary. Everyone shall
be treated with dignity and respect.
Last Name - First Name - Middle Name or Initial
Last 4 #SSN (optional)
Date of Birth
Medical Conditions/Patient Goals:
Cardiopulmonary Resuscitation (CPR): Person has no pulse and is not breathing.
When not in cardiopulmonary arrest, go to part B.
Do Not Attempt Resuscitation/DNAR (Allow Natural Death)
Choosing DNAR will include appropriate comfort measures.
Medical Interventions: Person has pulse and/or i