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Healthcare MOLST Form

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HEALTHCARE MOLST FORM (Medical Orders for Life-Sustaining Treatment)

Patient Name:    Date of Birth:

Patient Identification & Contact

Advance Directive & Decision-Maker

Advance Directive/Health Care Proxy present:

Medical History (Relevant)

Medical Orders (Select applicable orders)

Cardiopulmonary Resuscitation (CPR):

Medical Interventions (select one):

Antibiotics and Other Interventions

Antibiotics for life-threatening infection:



Capacity & Consent

Patient capacity assessment:

Statement of explanation given by clinician: I have explained the medical condition, prognosis, and the nature and consequences of the selected orders. The patient or the patient's legally authorized representative understands these orders and the right to revoke or modify them at any time.

Clinician Attestation (Medical Order)

The clinician attests that the orders above reflect current medical orders to be honored across care settings. These orders are intended to be actionable medical orders and to remain in effect until amended or revoked by the patient or authorized representative.

Acknowledgment & Witness

Witness (if required by facility): I attest that the patient or authorized representative appeared to understand and voluntarily agree to the orders recorded on this form.

Patient Printed Name:

Signature:

Date:

Relationship to Patient (if signed by representative):

By signing above, the signer affirms that they are the patient or the patient's legally authorized representative and that the information and choices entered on this form are accurate and represent current medical orders to be followed by healthcare providers.

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What the Healthcare MOLST Form Is and when it applies

The Healthcare MOLST Form (Medical Orders for Life-Sustaining Treatment) is a standardized medical order that records a seriously ill patient’s preferences about life-sustaining treatments and CPR. It translates patient goals and clinician instructions into portable, actionable orders that follow the patient across care settings, including hospitals, long-term care, and emergency care. The form is completed by a clinician in consultation with the patient or an authorized surrogate, and once signed it functions as a physician’s order that emergency responders and facility clinicians should follow.

Why accurate MOLST completion matters

A properly completed Healthcare MOLST Form ensures patient treatment preferences are documented as medical orders, reducing unwanted interventions in emergencies and aligning care with goals.

Why accurate MOLST completion matters

Who typically completes and relies on a Healthcare MOLST Form

The form is used across clinical settings; different roles have distinct responsibilities when creating, signing, and enforcing MOLST orders.

  • Patients or surrogates who discuss goals of care and consent to medical orders for life-sustaining treatment.
  • Physicians, nurse practitioners, or physician assistants who enter and sign the medical orders on the MOLST Form.
  • Emergency medical services (EMS) and facility clinicians who must follow the medical orders during transport and care transitions.

Clear role delineation helps ensure the form is valid, accessible, and followed during emergency or routine care transitions.

Step-by-step: how to complete a Healthcare MOLST Form

Follow this concise sequence to create a valid, portable MOLST order that reflects patient goals and meets clinical requirements.

  • 01
    Discuss goals: Conduct goals-of-care conversation with patient or surrogate.
  • 02
    Document choices: Record specific life-sustaining treatment preferences on the form.
  • 03
    Clinician order: Licensed clinician signs and dates the form to make it a medical order.
  • 04
    Distribute copies: Provide the patient, other care sites, and EMS with copies.

Essential components of a professional Healthcare MOLST Form

A complete MOLST form contains defined sections that make orders clear, enforceable, and portable between care settings.

Patient identification

Full legal name, date of birth, and medical record number to ensure the order applies to the correct individual.

Specific medical orders

Explicit selections for CPR, respiratory support, antibiotics, IV fluids, and other life-sustaining interventions.

Capacity and consent

Statement of patient's decision-making capacity and documentation of informed consent or surrogate decision-maker authority.

Clinician authentication

Signature, printed name, professional title, license or NPI number, and date to convert preferences into orders.

Emergency instructions

Clear guidance for EMS about whether to initiate resuscitation or other prehospital interventions.

Revision history

Space for amendments, dates, and clinician initials so changes are tracked across care transitions.

Confidential data and security considerations

Protected Health Information: Patient identifiers and clinical decisions
Access controls: Role-based limits on who can view or edit
Audit trail: Record of who signed and when
Encryption: TLS in transit; AES-256 at rest
HIPAA compliance: BAA required for eHealth vendors
Retention controls: Defined policy for archiving and deletion

Common preparation pitfalls to avoid

  • Incomplete identification fields or mismatched names that prevent identification in emergency settings and create delays in care.
  • Vague or conflicting treatment selections that leave clinicians uncertain whether to initiate life-sustaining interventions.
  • Missing clinician signature, license, or date which can render the MOLST order non-actionable under facility or EMS protocols.
  • Failure to distribute signed copies to EMS, family, and receiving facilities, reducing the form’s portability during transitions.

Legal and clinical risks of incorrect or absent MOLST orders

Clinical harm: Unwanted treatment or lack of indicated care
Regulatory exposure: HIPAA violations for improper disclosures
Civil liability: Malpractice claims for failure to follow wishes
Criminal risk: Rare, but possible in extreme misconduct cases
Operational delays: Lost time locating valid orders
Probate complications: Conflict with advance directives or POA

Where the MOLST form travels during care transitions

This sequence shows typical routing so the form remains actionable across settings.

  • Hospital origin: Form completed and signed by treating clinician.
  • Patient copy: Patient or surrogate carries a copy for home use.
  • EMS access: EMS uses orders during emergency response.
  • Receiving facility: Long-term care or hospice incorporates orders into chart.

How to configure a digital MOLST workflow

Configure fields and routing to match clinical approval and distribution requirements before issuing the form electronically.

Field Configuration
Patient ID Auto-populate from EHR
Clinician sign-off Require licensed signer then timestamp
Surrogate notification Auto-email on completion
EMS copy Generate printable summary

Technical considerations for eSigning and eSubmission

Ensure the platform supports secure authentication, audit trails, and HIPAA-compliant handling of health records.

  • Authentication: Email + optional SMS or KBA
  • Integrations: EHR, Google Drive, Box, NetSuite
  • Document formats: PDF, DOCX supported

Timing: when to review, renew, or re-sign a MOLST form

Regular review ensures the MOLST reflects current goals; certain circumstances require immediate reassessment and re-signature.

Initial completion:

At diagnosis of serious illness or during hospitalization

After change in condition:

Revisit immediately after significant clinical change

Periodic review:

Recommend annual review or upon major life event

Transfer of care:

Confirm orders at each transfer or discharge

Revocation:

Patient may revoke in writing; document date and signature

Typical eSignature vendor pricing and capabilities relevant to MOLST workflows

Comparison of common plan starting prices and feature availability across vendors; signNow is listed first per table rules and all entries reflect commonly published plan data.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes (Business Premium) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA required) Yes Yes No No

Real-world examples of MOLST use

These short case summaries illustrate typical application and benefits of a correctly completed MOLST form in care settings.

Hospital to Home

Patient with advanced COPD documents DNR and comfort-directed treatments on the MOLST

  • EMS follows orders during an emergency transport
  • The consistent orders prevent unwanted intubation and align prehospital care with patient goals, reducing distress and unnecessary procedures.

Nursing Facility Admission

Resident admitted after stroke has MOLST updated to reflect new goals

  • Facility clinician signs the revised order
  • Staff use the updated MOLST at medication changes and when communicating with family and EMS, ensuring continuity across shifts.

Frequently asked questions about the Healthcare MOLST Form

Answers to common questions about validity, signatures, portability, and how to correct or revoke a MOLST form.


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