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Click ‘Get Form’ to open the Montana POLST form in our editor.
Begin by entering the patient's first and last name, along with their date of birth. Ensure this information is accurate as it identifies the individual for whom the orders apply.
In Section A, select one option regarding Cardiopulmonary Resuscitation (CPR). Choose either 'Resuscitate (Full Code)' or 'Do Not Resuscitate (No Code)'. Only one box should be checked.
Proceed to Section B for Medical Interventions. Select one option that best describes the level of care desired if the patient has a pulse and is breathing. Options include Comfort Measures, Limited Additional Interventions, or Full Treatment.
In Section C, indicate preferences for Artificial Fluids and Nutrition by selecting options for feeding tubes and IV fluids. You may select more than one option here.
Section D allows you to note any Advance Directives that exist. Specify if there are any additional documents like a Living Will.
Finally, ensure Section E is completed with signatures from both the patient or surrogate and the physician/APRN/PA. This section is crucial for validating the POLST form.
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Yes, the POLST can be modified or revoked by a patient, verbally or in writing, at any time. Changes may also be made by a physician, or requested by a patients decisionmaker, based on new information or changes in the patients condition.
How do I revoke a POLST?
If you want to void or cancel your POLST form you can. There are two steps to take: Write VOID in large letters across it or destroy the document. Tell your provider you have done thisthis is important!
Can a POLST be reversed?
Just as with DNR orders, family members generally cannot override a patient- and physician-signed POLST order. Accordingly, all efforts should be made to get patients, families, and providers on the same page before an acute event, to prevent confusion about the plan of care and distress for families and providers.
How to void a polst?
To void a POLST form, draw a line through sections A through D, write VOID in large letters, then sign and date the line. form is a legally valid physician order. Any section not completed implies full treatment for that section. CARDIOPULMONARY RESUSCITATION (CPR): If patient has no pulse and is not breathing.
How to discuss Polst?
1) Key elements that should be included in the synopsis of the discussion that is documented in the office note (Remember, if you dont document, it didnt happen.): a) Patients appropriateness for having a POLST Form, including medical condition(s), health status and prognosis b) Presence of any advance directive
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Montana Provider Orders for Life-Sustaining Treatment (
Use of the original form is strongly encouraged. Photocopies and FAXs of signed POLST forms are legal and valid. The patient should retain the original on
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