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Healthcare POLST Form

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Healthcare POLST Form

Patient Information

Patient Name:     Date of Birth:

     

Insurance Information

Medical History

Advance Directive & Surrogate Decision-Maker

Advance Directive Exists:   

Orders (Medical Orders for Life-Sustaining Treatment)

These orders are medical orders intended to be honored by health care professionals across settings. They reflect the current medical treatment preferences of the patient as documented below. The clinician signing certifies that these orders reflect the informed choices of the patient or the patient's legally authorized surrogate.

A. Cardiopulmonary Resuscitation (CPR)

Select one option only. These orders apply in the event of cardiac or respiratory arrest.


B. Medical Interventions

Check the medically appropriate level of intervention to be provided if the patient has a pulse and is breathing. If multiple boxes are checked, the most restrictive order will be interpreted as controlling.



C. Antibiotics



D. Artificial Nutrition



Legal and Administrative Statements

These orders remain in effect until they are reversed by the patient or the patient's legally authorized representative, or until superseded by a later medical order. Health care professionals must follow these orders to the extent allowed by law and clinical judgement. This form is intended to be a portable medical order across care settings.

The clinician signing below certifies that the patient or the patient's legally authorized surrogate participated in the discussion of prognosis, treatment options, and likely outcomes and that the orders accurately reflect the informed preferences expressed. If the patient lacks capacity, the clinician documents that the surrogate has the legal authority to make these decisions.

Consent Acknowledgment: I acknowledge that the POLST form documents medical orders and that I have had the opportunity to discuss the treatment options, benefits, risks, and likely outcomes with the clinician. I understand that I may revoke or modify these orders at any time by communicating with my treating clinician or by completing a new POLST form.

HIPAA / Privacy Acknowledgment

I authorize the release of medical information necessary to carry out these orders and to communicate with health care providers responsible for the patient's care. I acknowledge receipt of privacy protections related to my health information.

Provider Information (for clinician completing POLST)

Patient/Surrogate Name:

By:

Date:

Clinician Name:

By:

Date:

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What the Healthcare POLST Form Is and when it applies

The Healthcare POLST Form (Physician Orders for Life-Sustaining Treatment) is a portable, medical order documenting a seriously ill patient's preferences for CPR, medical interventions, antibiotics, and artificial nutrition. POLST translates patient goals into actionable clinician orders that travel across care settings, including hospitals, nursing homes, and EMS. It complements advance directives by providing immediate orders for treating clinicians and typically requires a clinician's signature plus the patient or authorized surrogate signature to be valid and actionable during emergency or routine care.

Why a POLST Form matters for patient-centered care

A completed POLST Form reduces ambiguity about treatment preferences, aligns care with patient goals, and gives clinicians clear standing medical orders. It improves continuity across settings, reduces unwanted or non-beneficial interventions, and supports timely decisions when patients cannot speak for themselves.

Why a POLST Form matters for patient-centered care

Who completes and relies on a POLST Form

The POLST Form is completed and used by the patient, the treating clinician, and facility or emergency staff to document and act on immediate treatment orders.

  • Patients with advanced or life-limiting illness who want portable, actionable medical orders.
  • Physicians, nurse practitioners, or physician assistants who are authorized to write medical orders.
  • Long-term care staff and EMS personnel who must follow standing treatment orders during transitions.

Keep the POLST Form accessible in the medical chart, with the patient, and with emergency contact persons; update after major clinical changes.

Primary signers and their roles

Patient — Decision maker

Patients (or their legally authorized surrogates) express values and specific treatment preferences; signing indicates consent to the clinician's orders and confirms the patient's goals of care.

Clinician — Ordering authority

A licensed clinician (physician, APRN, or PA) reviews goals, documents medical orders on the POLST form, and signs to make the form a standing medical order enforceable by other clinicians and EMS.

Core sections you’ll find on a professional POLST Form

A standard POLST Form contains a concise set of clinician orders and administrative fields so that treating teams can act quickly and consistently across settings.

Patient ID

Full legal name, date of birth, and medical record identifiers to ensure the form matches the correct patient and prevents misapplication of orders.

CPR / Code Status

Explicit choice about cardiopulmonary resuscitation (attempt or do not attempt) so EMS and clinicians know whether to start chest compressions and advanced cardiac life support.

Medical Interventions

Specific directive on levels of treatment (e.g., full treatment, limited interventions, comfort-focused care) that guide hospital and long-term care responses.

Antibiotics & Nutrition

Preferences for antibiotics and artificial nutrition (tube feeding) that communicate patient goals regarding infection treatment and life-sustaining nourishment.

Signatures

Clinician signature, date, and clinician license number; patient or surrogate signature and relationship to patient to validate consent and authority.

Clinician Contact

Ordering clinician name and phone so receiving clinicians can clarify orders or confirm clinical intent when needed.

Step-by-step: completing a POLST Form

Follow a short, clinician-led process to document and implement POLST orders accurately.

  • 01
    Review: Confirm diagnosis, prognosis, and current treatment goals with the patient or surrogate.
  • 02
    Discuss options: Explain CPR, interventions, antibiotics, and nutrition including likely outcomes and burdens.
  • 03
    Document orders: Clinician completes order sections and enters license information.
  • 04
    Sign and distribute: Patient/surrogate and clinician sign; copies placed in chart and given to patient and EMS if applicable.

Updating or amending an existing POLST

Revisit POLST after major clinical changes; the form must reflect current treatment goals to remain valid.

01

Assess:

Confirm change in prognosis or goals.
02

Discuss:

Hold shared decision discussion with patient/surrogate.
03

Revise:

Clinician updates orders physically or electronically.
04

Sign:

All required signatures and dates recorded.
05

Distribute:

New copies issued to chart, patient, and EMS.
06

Void prior:

Document prior form as superseded or void.

Where to place and send the completed POLST

Once signed, the POLST Form must be stored and shared so treating clinicians can find it quickly.

  • Medical record: File the original in the patient's active medical record or electronic health record (EHR).
  • Patient copy: Provide a clear patient-facing copy to keep at home and with caregivers.
  • EMS access: Ensure EMS knows where to find the form or has access via state registry or wallet card.
  • Facility transfer: Include the POLST with transfer paperwork during hospital or facility moves.

Digital handling: eCompletion and eSubmission

Many organizations digitize POLST Forms for easier distribution and recordkeeping but must preserve medical-order integrity.

  • Document formats: PDF or structured EHR form for reliable viewing and audit.
  • Authentication: Clinician identity verification via professional login or two-factor authentication.
  • Audit trail: Timestamped record of completion and any subsequent amendments.

When using e-signature platforms, ensure HIPAA safeguards, clinician authentication, and retention of an auditable record matching regulatory requirements.

Key fields required on a POLST Form

Patient Name: Full legal name
Date of Birth: MM/DD/YYYY
Medical Record: MRN or identifier
Orders: CPR and interventions
Signatures: Clinician and patient
Clinician ID: License number

Timing considerations and when a POLST takes effect

POLST orders are effective when signed by the clinician and the patient or surrogate; timing and registry submission vary by program and state.

Effective date:

Form is effective on the clinician signature date

Immediate use:

Orders apply immediately in emergencies and routine care

Updates:

Update after major clinical or preference changes promptly

Registry submission:

Some states encourage electronic registry entry within days

Expiration:

No universal expiration; review periodically with care team

Notarization, witnessing, and authentication steps

Notarization and witness requirements for POLST Forms vary by state and facility; follow local rules when present.

01

Check state rules

Verify whether your state or health system requires notarization or witness.

02

Witness presence

If required, arrange witness at time of signing.

03

Notary options

Use in-person or permitted remote online notarization (RON) where allowed.

04

Clinician attestation

Clinician documents clinical discussion and informed consent.

05

Retain record

Keep the signed form and any notary journal entries.

06

EHR upload

Scan or upload notarized form to the EHR.

07

EMS copy

Provide EMS with a patient copy if used in the field.

08

Void prior forms

Mark superseded POLST forms as void in the record.

Common mistakes to avoid when preparing POLST

  • Using abbreviations or nicknames that prevent reliable patient identification and cause chart mismatches.
  • Failing to obtain the required clinician signature or license number, which can render orders non-actionable.
  • Not updating the POLST after a major change in condition, leaving outdated orders in circulation.
  • Distributing incomplete copies that omit clinician signature or dates, creating uncertainty for EMS and facility staff.

Potential legal and clinical risks of incorrect POLST completion

Noncompliance: Delayed treatment
Invalid signature: Orders not enforceable
Misidentification: Wrong patient care
HIPAA exposure: Privacy breach risk
Conflicting orders: Care team confusion
Documentation gaps: Liability exposure

eSignature vendor comparison for completing POLST Forms

Basic capability needs for POLST include clinician authentication, HIPAA support, audit trails, and secure PDF output; vendor pricing and plan features vary.

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 Yes, 7-day free trial Yes, trial available Yes, trial available Yes, trial available Yes, trial available
Bulk Send Yes; no envelope cap Yes; 100 envelopes/user/year cap Yes; depends on plan Yes; depends on plan Yes; depends on plan
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA required) Yes Yes No No

Illustrative usage scenarios

Two short scenarios show typical POLST workflows across care settings.

Hospital to Home

A hospitalized patient with progressive lung disease discussed goals with the care team and completed a POLST before discharge to home hospice.

  • EMS used the POLST during an after-hours transfer to honor comfort-focused orders.
  • The POLST was scanned into the EHR, a patient copy was given to the family, and clinicians avoided unwanted resuscitation attempts during a subsequent crisis.

Nursing Facility Update

A long-term care resident had a significant decline and requested limited interventions; the clinician reviewed options and updated POLST accordingly.

  • Staff placed the new POLST at bedside and in the chart.
  • The updated POLST prevented inappropriate hospital transfer and guided in-facility palliative measures consistent with the resident's wishes.

Frequently asked questions about POLST completion and validity

Answers to frequent practical and legal questions about creating, signing, and using POLST Forms in clinical practice.


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