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IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment (POLST) Form 2017-2026 free printable template

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DPH POST ascribed in Selective Treatment and ComfortFocused Treatment, use intubation, mechanical ventilation and cardioversion as indicated. Transfer to hospital and/or intensive care unit if indicated.
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IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment (POLST) Form Form Versions

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IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment (POLST) Form 2017
4.8 Satisfied (30 Votes)
IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment (POLST) Form 2015
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How to fill out IL IDPH Uniform Practitioner Orders for Life-Sustaining

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How to fill out IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment

01
Obtain the IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment form from a healthcare provider or referral resource.
02
Complete patient identification information, including the patient's name, date of birth, and medical record number.
03
Discuss the treatment options with the patient or their legal decision-maker to ensure understanding of all choices.
04
Mark the appropriate boxes on the form for each treatment option: Full treatment, Limited treatment, or Comfort care.
05
Specify any additional orders or preferences regarding resuscitation and other interventions.
06
Ensure signatures from the patient (if applicable), their legal representative, and the attending physician.
07
Review the completed form for accuracy and clarity before distributing copies to the relevant healthcare teams.
08
Regularly revisit and update the order as the patient's condition or preferences change.

Who needs IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment?

01
Individuals with serious, life-limiting illnesses who wish to express their preferences regarding medical treatment.
02
Patients residing in long-term care facilities or those who may enter such facilities.
03
Individuals undergoing treatment for end-of-life care decision-making.
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The IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment is a standardized form used in Illinois that allows individuals to express their preferences for life-sustaining treatment in emergency medical situations, ensuring that their wishes are honored.
Individuals who are seriously ill or have a progressive chronic illness are encouraged to complete and file the IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment to communicate their healthcare preferences to medical providers.
To fill out the IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment, individuals should consult with their healthcare provider to discuss their treatment preferences, then complete the form with relevant medical and personal information and ensure it is signed by both the individual and their healthcare practitioner.
The purpose of the IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment is to provide clear and legally binding instructions for emergency medical personnel regarding a patient's wishes about life-sustaining treatment, facilitating decision-making in critical situations.
The IL IDPH Uniform Practitioner Orders for Life-Sustaining Treatment must include the patient's name, date of birth, medical conditions, preferred treatment options, signatures of the patient and the physician or healthcare practitioner, and the date of the order.
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