Minnesota POLST Form - Free Download
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Minnesota POLST Form
Minnesota POLST Form
A
Check
One
Cardiopulmonary resusCitation (Cpr):
Patient has no pulse and is not breathing.
When not in cardiopulmonary arrest, follow orders in B and C.
B
Check
One
Goal
goals of treatment:
Patient has pulse and/or is breathing. See Section A regarding CPR if pulse is lost.
C
Check
All That
Apply
interventions and treatment
Provider Name (MD/DO/NP/PA when delegated, are acceptable) Provider Signature Date
Last Name
First/Middle Initial
Date of Birth
Primary Care Provider/Phone
POLST: Provider Orders for Life Sustaining Treatment
Hipaa permits disClosure of polst to otHer HealtH Care providers as neCessary
provider orders for
life-sustaining treatment (polst)
FIRST follow these orders, THEN contact the patients provider. is
is a provider order sheet based on the patients medical condition and
wishes. POLST translates an advance directive into provider orders.
Any section not completed implies the most aggressive treatment
for that section. Patients should always be treated with dignity and
respect.
Cpr/attempt resusCitation dnr/do not attempt resusCitation (Allow Natural Death)
Comfort CareDo not intubate but use medication, oxygen, oral suction, and manual
clearing of airways, etc. as needed for immediate comfort.
Check all that apply:
Avoid calling 911, call ______________________________ instead
If possible, do not transport to ER (when patient can be made comfortable at residence)
If possible, do not admit to the hospital from the ER (e.g. when patient can be made com-
fortable at residence)
limit interventions and treat reversible Conditions Provide interventions aimed at treatment of new or reversible ill-
ness / injury or non-life threatening chronic conditions. Duration of invasive or uncomfortable interventions should generally
be limited. (Transport to ER presumed)
Check one:
Do not intubate
Trial of intubation (e.g.______days) or other instructions: _______________________________________________________
Intubate long-term if necessary
provide life sustaining treatment
Intubate, cardiovert, and provide medically necessary care to sustain life. (Transport to ER presumed)
Additional Orders (e.g. dialysis, etc.)
Additional Orders:
antibiotiCs (check one):
No Antibiotics (Use other methods to relieve symptoms whenever possible.)
Oral Antibiotics Only (No IV/IM)
Use IV/IM Antibiotic Treatment
nutrition/Hydration (check all that apply):
Offer food and liquids by mouth (Oral fluids and nutrition must always be
offered if medically feasible)
Tube feeding through mouth or nose
Tube feeding directly into GI tract
IV fluid administration
Other:
An automatic external debrillator (AED) should not be used for a
patient who has chosen “Do Not Attempt Resuscitation.”
faxed Copies and pHotoCopies of tHis form are valid.
to void tHis form, draw a line aCross seCtions a - d and write “void” in large letters.
POLST
POLST
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