Is a POLST the same as an advance directive?

No. An advance directive states long-term wishes and appoints a surrogate; a POLST is a clinician-signed medical order for immediate treatment preferences when the patient is seriously ill.

Who must sign the POLST?

A licensed clinician must sign to make the form an actionable medical order; the patient or an authorized surrogate should also sign or acknowledge when required.

Can POLST be completed electronically?

Yes. Electronic completion is acceptable when the platform provides reliable authentication, an audit trail, and complies with HIPAA and applicable state rules; retain evidence of consent and the record.

How do I update or revoke a POLST?

Document the new patient preferences, have a clinician sign a revised POLST, mark the prior form as superseded, and distribute the updated form to care partners immediately.

Are witnesses or notarization required?

Requirements vary by state and form version; some states do not require witnesses while others may recommend or require them—check state guidance when in doubt.

What if POLST conflicts with other documents?

Treat the POLST as a medical order; clinicians should reconcile conflicts with the patient, surrogate, and legal documents and document the rationale and any legal consultation.

Electronic Signature
Templates
Healthcare
Healthcare POLST Document

Healthcare POLST Document

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

POLST — Physician Orders for Life‑Sustaining Treatment

Patient Identification

Patient Name:

Date of Birth: Medical Record Number:

Address

Phone

Emergency Contact (Name, Relationship, Phone)

Insurance and Coverage

Insurance Provider

Policy Number

Group Number / Subscriber

Medical History

Current Medications Allergies Prior Surgeries / Significant Conditions

Orders (Medical Treatment Preferences)

The following are physician orders based on informed discussion with the patient or legal decision‑maker. These orders are intended to be followed across care settings and remain in effect until revoked or replaced by a subsequent valid order.

A. Cardiopulmonary Resuscitation (CPR)

Select one:
Attempt Resuscitation (CPR) — Attempt chest compressions, defibrillation, and advanced cardiac life support as indicated.
Do Not Attempt Resuscitation (DNR) — Do not attempt chest compressions, defibrillation, or advanced cardiac life support if cardiopulmonary arrest occurs.

B. Medical Interventions

Select the level of medical interventions desired when the patient has a pulse and/or is breathing:
Full Treatment — Includes intubation and mechanical ventilation, cardioversion, transfer to higher level of care including intensive care when indicated.
Selective/Intermediate Treatment — Medical and/or invasive treatments such as IV fluids, antibiotics, oxygen as indicated; may exclude intubation and escalation to intensive care per clinical judgment and prior stated preferences.
Comfort‑Focused Treatment Only — Prioritize symptom relief and comfort; avoid aggressive life‑prolonging interventions and hospital transfer unless required for comfort.

C. Antibiotics

Preferences for use of antibiotics:
Use antibiotics when indicated for curative intent or symptom relief.
Limited use — Use antibiotics only for symptom relief or limited courses as indicated by clinical judgment.
Avoid antibiotics except to relieve suffering.
No antibiotics.

D. Artificially Administered Nutrition

Preferences regarding tube feeding:
Long‑term artificial nutrition offered (including PEG tube) as appropriate.
Time‑limited trial of artificial nutrition to assess benefit.
No artificial nutrition by tube; provide oral intake as tolerated for comfort.

E. Additional Orders / Limitations

Additional Instructions

F. Advance Directive and Decision‑Maker

Is there an Advance Directive or Durable Power of Attorney for Health Care on file?
Yes No

If patient lacks decision‑making capacity, name of legal decision‑maker or surrogate

Clinician Attestation

I attest that I have discussed the patient's current health status, prognosis, and the patient's preferences regarding life‑sustaining treatment with the patient and/or the legally authorized decision‑maker. The orders above reflect the informed preferences expressed by the patient or their legal surrogate, and are intended as actionable medical orders.

Clinician / Provider Name

License / NPI Number

Clinician Contact

Facility / Location where order was written Date of discussion / order entry

Legal Acknowledgment and Effect

These orders are medical orders that must be honored by healthcare professionals and emergency responders. The patient or their legally authorized representative may revoke or modify these orders at any time and must inform the treating clinician. If there is a conflict between these orders and other advance directives, the most recent valid medical order or the patient's expressed wish shall govern. This document remains in force until a new POLST or equivalent order is executed or it is otherwise lawfully revoked.

Review / Expiration

Recommended review date: Document expires or should be reviewed upon major change in health status:

Verification of Understanding

I confirm that I have had the opportunity to discuss the foregoing orders, that my questions have been answered, and that I understand the nature and consequences of these orders. I understand that these orders are actionable medical orders.

Patient Name:

Signature:

Relationship (if signed by surrogate):

Date:

What the Healthcare POLST Document Is

The Healthcare POLST Document (Physician Orders for Life-Sustaining Treatment) is a portable medical order completed for patients with serious illness or frailty to record clinician-guided treatment preferences. It translates a patient’s goals and current treatment wishes into actionable medical orders — for example, choices about resuscitation, medical interventions, antibiotics, and artificial nutrition — that travel with the patient across care settings. POLST is distinct from an advance directive: it is a clinician-signed order intended to be followed by emergency responders and treating clinicians when a patient’s condition warrants immediate medical decisions.

Why a POLST Document Matters for Patient Care

A properly completed Healthcare POLST Document ensures a patient’s treatment preferences are documented as medical orders that can be immediately followed by clinicians and EMS, reducing unwanted interventions and aligning care with goals. It supports clearer decision making during emergencies and care transitions.

Who Typically Completes or Relies on a POLST

The POLST process involves the patient (or authorized surrogate), the treating clinician, and often outpatient or facility-based care staff.

Clinicians and Prescribers: physicians, nurse practitioners, or physician assistants who review goals of care and sign the POLST.
Patients or Surrogates: seriously ill or frail adults who want medical orders that reflect current treatment choices.
EMS and Acute Care Teams: first responders and hospital clinicians who use POLST orders during emergencies.

Each party has a defined role: clinicians confirm clinical appropriateness, patients express preferences, and care teams implement the documented orders.

Core Elements Found on a Professional POLST

A complete Healthcare POLST Document includes concise, actionable sections so clinicians and responders can follow patient preferences without ambiguity. Standard components address resuscitation, intervention level, artificial nutrition, antibiotic use, and signatures.

CPR / DNR

Clear selection for cardiopulmonary resuscitation or do-not-resuscitate status to guide emergency response.

Medical Interventions

Specifies full treatment, limited interventions, or comfort-focused care for non-arrest medical events.

Artificial Nutrition

Documents preferences about tube feeding or other long-term nutrition support in specified clinical contexts.

Antibiotics

Indicates whether antibiotics should be used for life-threatening or symptomatic infections based on patient goals.

Clinician Signature

A licensed clinician signs and dates the POLST to convert preferences into medical orders.

Patient/Surrogate

Patient or legally authorized surrogate signs or acknowledges the form; documentation of discussion and consent is recorded.

Step-by-Step: Completing a Healthcare POLST Document

Follow these sequential steps to create a valid POLST that clinicians and EMS can follow.

01

Discuss goals: Conduct a goals-of-care conversation with the patient or surrogate.
02

Document choices: Record resuscitation and treatment preferences clearly on the POLST.
03

Clinician order: Have an authorized clinician review and sign the order section.
04

Distribute copies: Provide the patient, caregivers, and receiving providers with the completed POLST.

Where to File or Send the Completed POLST

After signing, route the Healthcare POLST Document to the appropriate individuals and systems so it is accessible during care transitions.

Give to patient: Provide a printed copy to the patient or surrogate to carry across settings.
Upload to EHR: Place a scanned or discrete EHR entry so treating clinicians can find the order quickly.
Share with EMS: Inform local EMS systems if the jurisdiction supports POLST registries or electronic access.
Send to receiving facility: Transmit a copy with transfer paperwork when the patient moves between care sites.

Digital Signing and eSubmission Considerations

Electronic completion and secure eSubmission can accelerate access, but platforms must meet clinical and legal requirements.

Document formats: PDF or DOCX are accepted for EHR upload and archiving.
Authentication: Use robust signer authentication (email + SMS or institutional SSO) for clinician sign-off.
Privacy: Ensure HIPAA controls and, where required, a BAA are in place for the eSignature vendor.

Choose a platform that supports audit trails, access controls, and formats compatible with local POLST registries and EHRs.

Time-Sensitive Steps and Typical Processing Expectations

Certain actions and notifications are time-sensitive; this list shows common timeframes to plan for.

Immediate Effect:

A signed POLST becomes effective upon clinician signature and patient/surrogate acknowledgement.

During Transfer:

Provide POLST document at the time of transfer to receiving facility or EMS to prevent delays.

Registry Submission:

If a state POLST registry exists, upload or notify within local timelines — often within days.

Annual Review:

Review POLST choices when clinical status or goals change; many clinicians schedule at least annual check-ins.

Revision Notice:

Document any revisions immediately; superseding orders should be clearly marked and dated.

Key Milestones in POLST Completion and Follow-Up

A sequential milestone view helps coordinate clinical discussion, ordering, and distribution across teams.

01

Goals Conversation

Conduct an in-depth discussion about prognosis, values, and treatment options.

02

Decision Documentation

Translate chosen goals into clear POLST selections during the clinical encounter.

03

Clinician Signing

Have a licensed clinician sign and date the POLST to create a valid medical order.

04

Distribution

Ensure copies reach the patient, caregivers, EMS, and receiving facilities without delay.

Common Mistakes to Avoid When Preparing a POLST

Incomplete clinician signature or missing date — unsigned orders are not enforceable and cause treatment delays.
Conflicting selections marked in multiple sections — ambiguity can lead to unintended interventions.
Failing to distribute copies to EMS or receiving facilities — POLST must travel with the patient for effectiveness.
Not updating the form after a significant change in health status — outdated orders may not reflect current wishes.

Risks and Legal Consequences of Errors on POLST

Clinical Risk: Unintended treatments or withheld care if orders are unclear or absent.

Legal Exposure: Potential liability for providers who do not follow valid medical orders or who rely on invalid forms.

Regulatory Risk: Noncompliance with state POLST program rules may affect facility reporting obligations.

Patient Harm: Emotional and clinical harm when documented preferences are not honored.

Recordkeeping Failures: Lost or missing POLST documents impair continuity of care.

Audit Findings: Facilities may face corrective actions after quality or compliance audits.

Required Information and Metadata for the POLST Record

Patient ID: Full legal name and DOB

Clinical Orders: CPR and treatment-level choices

Signatures: Clinician and patient/surrogate signature

Dates: Signature and effective dates

Clinician Details: License number and contact info

Distribution Log: Record of persons and systems receiving the POLST

Real-World Examples of POLST Use

These short examples show typical situations where a POLST guided care consistent with patient goals.

Community Palliative Care

A frail elder discussed goals with a clinician and completed a POLST

EMS followed the Do Not Attempt CPR order during a cardiac arrest
The patient died per preferences without unwanted resuscitation, family reported care aligned with wishes and fewer hospital transfers.

Nursing Facility Transfer

A nursing facility updated a resident’s POLST after a change in condition

The facility transmitted the updated POLST to the receiving hospital
The hospital team implemented comfort-focused orders and avoided invasive ICU care, consistent with documented goals.

Practical Tips for Accurate and Efficient POLST Completion

Follow these best practices to improve clarity and reduce future disputes.

Use plain language

Document decisions in clear, unambiguous terms so EMS and other clinicians can act quickly without interpretation.

Keep copies available

Provide the patient and caregivers with a printed copy and upload to the EHR and any state registry if available.

Schedule reviews

Reassess POLST after major health changes and document revisions immediately to avoid conflicting orders.

Coordinate with advance directive

Ensure POLST choices align with the patient’s advance directive and note any conflicts in the medical record.

Comparison: eSignature Pricing and Key Features for POLST Workflows

This vendor comparison focuses on basic pricing and several features relevant when selecting an eSignature provider for clinical orders and HIPAA-covered workflows.

	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 vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About the Healthcare POLST Document

Answers to common questions about validity, signatures, updates, and digital delivery of POLST forms in clinical practice.

Need help? Contact support

Is a POLST the same as an advance directive?
No. An advance directive states long-term wishes and appoints a surrogate; a POLST is a clinician-signed medical order for immediate treatment preferences when the patient is seriously ill.
Who must sign the POLST?
A licensed clinician must sign to make the form an actionable medical order; the patient or an authorized surrogate should also sign or acknowledge when required.
Can POLST be completed electronically?
Yes. Electronic completion is acceptable when the platform provides reliable authentication, an audit trail, and complies with HIPAA and applicable state rules; retain evidence of consent and the record.
How do I update or revoke a POLST?
Document the new patient preferences, have a clinician sign a revised POLST, mark the prior form as superseded, and distribute the updated form to care partners immediately.
Are witnesses or notarization required?
Requirements vary by state and form version; some states do not require witnesses while others may recommend or require them—check state guidance when in doubt.
What if POLST conflicts with other documents?
Treat the POLST as a medical order; clinicians should reconcile conflicts with the patient, surrogate, and legal documents and document the rationale and any legal consultation.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now