POLST cover sheets answer consumer questions at RCFEs and 2025

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4.8 out of 5

42 votes

The POLST Cover Sheet 2020 outlines the Physician Orders for Life Sustaining Treatment (POLST), a medical order designed to give individuals with serious illnesses more control over their emergency care preferences. It emphasizes that POLST is voluntary, complements advance directives, and must be completed by a healthcare provider after discussing treatment wishes with the patient. The document details the process for completing, reviewing, and voiding a POLST form, as well as its legal implications and requirements for healthcare providers.

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Click ‘Get Form’ to open the POLST cover sheet in the editor.
Begin by filling in the patient’s personal information, including 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: 'Full Treatment', 'Selective Treatment', or 'Comfort-Focused Treatment'.
In Section C, indicate preferences regarding artificially administered nutrition by selecting from the options provided.
Ensure that both the patient (or their legally recognized decisionmaker) and the physician sign the form for it to be valid.
Once completed, save your document. It is recommended to keep a copy in an easily accessible location for emergencies.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (42 Votes)
2011	4.4 Satisfied (50 Votes)
2009	4.7 Satisfied (28 Votes)

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Is POLST mandatory in California?

Filling out a POLST form is entirely voluntary. However, California law requires that the physician orders in a POLST be followed by health care professionals, and provides immunity from civil or criminal liability to those who comply in good faith with a patients POLST requests.

What is a polst form in California?

Physician Orders for Life Sustaining Treatment (POLST) is a medical order that helps give people with serious illness more control over their care during a medical emergency. POLST can help make sure you get the care you want, and also protect you from getting medical treatments you DO NOT want.

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