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Click ‘Get Form’ to open the POLST form in the editor.
Begin by filling in the patient’s information, including their last name, first name, middle name, date of birth, and medical record number if applicable.
In Section A, select either 'Attempt Resuscitation/CPR' or 'Do Not Attempt Resuscitation/DNR' based on the patient's wishes.
Proceed to Section B to choose the desired level of medical interventions: 'Comfort Measures Only', 'Limited Additional Interventions', or 'Full Treatment'.
In Section C, indicate preferences regarding artificially administered nutrition by selecting one of the options provided.
Complete the information and signatures section by discussing with the patient or legally recognized decision-maker and obtaining necessary signatures.
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The POLST decision- making process is for patients who are at risk for a life-threatening clinical event because they a serious life-limiting medical condition,
National POLST Collaborative | Portable Medical Orders
A POLST form translates patient wishes into medical orders that instruct medical teams what to do for a seriously ill person when they cannot speak forRead more
Nov 19, 2024 MOLST or POLST (Medical Orders for Life-Sustaining Treatment. MOLST/POLST should be documented and accessible to all providers across care
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