Get the free Sample POLST Form - CHAUSA

HIPAA PERMITS DISCLOSURE OF POST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY Last Name Physician Orders for Life-Sustaining Treatment (POST) First Name/ Middle Initial First follow these orders,

How to fill out sample polst form

How to fill out a sample POLST form:

1. Begin by reviewing the instructions provided with the form. Make sure you understand the purpose and importance of the POLST (Physician Orders for Life-Sustaining Treatment) form.
2. Start by filling out the patient's demographic information accurately. This includes their full name, date of birth, and contact information.
3. Next, provide details about the patient's current medical condition and any relevant medical history. This may include information about their diagnoses, allergies, and previous treatments.
4. Consider the patient's goals of care and preferences for certain medical interventions. Check the appropriate boxes or provide additional explanations based on their wishes regarding resuscitation, medical interventions, and artificial nutrition.
5. Discuss the form with the patient's healthcare provider or physician to ensure clarity and accurate completion. They can guide you through any specific medical terms or considerations that may arise.
6. Once completed, make sure all necessary signatures are obtained. This typically includes the patient's, healthcare provider's, and medical facility representative's signatures.
7. Keep a copy of the filled-out form for your records, and provide copies to the patient, their healthcare provider, and any other relevant parties involved in the patient's care.

Who needs a sample POLST form:

1. Patients with serious or chronic illnesses who may benefit from advance care planning.
2. Individuals with complex medical needs who may require immediate medical interventions or have preferences regarding life-sustaining treatments.
3. Those who wish to make their healthcare preferences known and ensure they are followed, especially in emergency situations.
4. Family members or caregivers involved in the patient's care, as they may be responsible for advocating for the patient's preferences and ensuring they are honored.
5. Healthcare providers and medical facilities where the patient is receiving care, as the POLST form provides clear instructions for medical professionals to follow regarding the patient's treatment options.

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