Is a POLST Full Code legally binding?

A POLST records clinician orders and is intended to be followed as medical orders. Electronic execution is generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and state UETA statutes where adopted; verify state-specific POLST program rules.

Can the POLST be signed electronically?

Many states accept electronic signatures if the platform meets e-signature law requirements and institutional policy; confirm e-signature acceptance with the state POLST program and follow consumer-disclosure rules when applicable.

Who may sign a POLST Full Code?

A licensed clinician authorized to write medical orders signs the POLST; the patient or legally authorized surrogate documents consent. State programs may specify clinician types and surrogate authority.

How do I change or revoke a POLST?

Changes require a new clinician order and signatures; note the revocation in the medical record and notify EMS, receiving facilities, and any state registry to prevent conflicting orders.

Where should a completed POLST be stored?

Keep the signed form in the patient’s medical record, provide copies to the patient and surrogate, and submit to the state registry if available to improve access by EMS and other providers.

Will a POLST from another state be honored?

Receiving clinicians should generally follow valid medical orders, but acceptance can vary by state and facility; when crossing jurisdictions, clarify local acceptance and consider re-documentation if needed.

Electronic Signature
Templates
Healthcare
Healthcare POLST Full Code

Healthcare POLST Full Code

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 (Full Code)

This document contains medical orders regarding cardiopulmonary resuscitation and other life-sustaining treatments. These orders are intended to be immediately actionable by health care professionals and emergency personnel. The person named below has participated in informed decision-making with a qualified clinician and consents to the orders recorded on this form. The patient or legally authorized representative may revoke or amend these orders at any time in accordance with applicable law and clinical judgment.

Patient Information

Patient Name:

Date of Birth: Gender: MRN:

Address Primary Contact Phone

Emergency Contact / Decision-Maker

Name Relationship Phone

Medical History & Current Status

Current Medications Allergies / Adverse Reactions Significant Past Medical/Surgical History / Chronic Conditions

Medical Orders

Cardiopulmonary Resuscitation (CPR)

Full Code — Attempt resuscitation. Perform cardiopulmonary resuscitation, defibrillation, advanced airway management, and administration of resuscitative medications as indicated.

Do Not Resuscitate (DNR) — Do not perform CPR if the patient has no pulse and is not breathing.

Medical Interventions

Select the level of medical intervention to be provided in the event of a life-threatening condition:

Comfort Measures Only — Focus on comfort; avoid hospitalization and invasive measures unless required for comfort.

Limited Additional Interventions — May include oxygen, IV fluids, antibiotics, and non-invasive ventilation as needed; hospitalize if indicated.

Full Treatment — Provide all medically appropriate interventions including advanced airway management, mechanical ventilation, and full critical care.

Specific Treatments

Intubation and Mechanical Ventilation are acceptable as part of resuscitation or full treatment.

Trial of Intubation — use temporary ventilatory support for a defined trial period as clinically indicated.

Use of Antibiotics — Use as indicated to treat infections; weigh benefits and burdens with family and clinical team.

Long-term Artificial Nutrition by tube is acceptable.

Other Orders / Clarifications

Clinician Attestation

The clinician attests that the patient or legally authorized representative participated in the discussion of goals of care, prognosis, treatment options, and likely outcomes, and that these orders reflect the informed preferences of the patient or representative.

Clinician Printed Name Professional License / License Number Role / Discipline Facility / Institution Clinician Contact Phone

Clinician attestation date:

Acknowledgment and Consent

I acknowledge that I have discussed these orders with the clinician named above and that the orders recorded on this form reflect my preferences for cardiopulmonary resuscitation and other life-sustaining treatments. I understand that these are medical orders to be followed by health care professionals and emergency responders. I understand I may revoke or amend these orders at any time by informing my clinician or health care provider.

I acknowledge receipt of the applicable privacy practices and that information on this form may be shared with other treating clinicians and emergency responders for the purpose of providing care.

Authorization expiration date:

Additional notes regarding decision-making capacity, surrogate authority, or limits on this POLST:

Patient/Authorized Representative:

Relationship:

Signature:

Date:

What the Healthcare POLST Full Code is and when it applies

The Healthcare POLST Full Code is a physician order form that records a patient’s preferences for life-sustaining treatment and directs clinical teams to follow those orders in emergencies. POLST stands for Physician Orders for Life-Sustaining Treatment and is used for patients with serious illness or frailty where clinicians expect a need to translate preferences into immediately actionable medical orders. A "Full Code" POLST indicates the patient requests all indicated resuscitative efforts, including cardiopulmonary resuscitation and advanced airway management, unless other clinical factors contraindicate those measures.

Why using a clear POLST Full Code matters for care consistency

A completed POLST Full Code converts patient goals into clinician orders that emergency and inpatient teams can follow immediately. It reduces ambiguity at critical moments, aligns interventions with the patient’s wishes, and supports coordinated care across settings while documenting clinical authority for requested treatments.

Who completes and relies on the Healthcare POLST Full Code

Practical uses and the primary participants involved when a POLST Full Code is completed.

Patients and surrogates: Patients with serious illness or their legally authorized decision-makers complete goals-of-care discussions.
Physicians and APRNs: Licensed clinicians enter the actual physician orders and clinical rationale.
Hospice, EMS, and nursing staff: Care teams use the POLST orders during transfers, emergencies, and routine care.

The POLST is intended to travel with the patient across care settings and be honored by clinicians and emergency personnel.

Essential sections included in a professional POLST Full Code

A fully completed POLST Full Code includes standardized sections so clinicians can rapidly interpret and act on a patient’s treatment preferences.

Patient identification

Full legal name, date of birth, and a unique medical record or identifier so orders attach unequivocally to the correct patient record and clinical chart.

Code status

Clear selection of 'Full Code' with any clinical limitations noted; this drives CPR and advanced airway choices during cardiac or respiratory arrest.

Medical interventions

Level-of-care orders such as full treatment, limited interventions, or comfort-focused measures, with specifics on ICU transfer and ventilator use if applicable.

Antibiotics

Choices about antibiotic use for life-threatening or non-life-threatening infections, recorded to guide infectious disease decisions consistent with patient goals.

Artificial nutrition

Preferences for tube feeding or intravenous nutrition, including temporary vs. long-term use, to inform decisions during prolonged incapacity.

Signatures and dates

Clinician signature, printed name, license or credential number, patient or surrogate signature, and the order date to validate clinical authority and timing.

Key data elements required on the POLST Full Code

Patient name: Legal name on ID

Date of birth: MM/DD/YYYY

Medical record number: Hospital or clinic MRN

Code status: Full Code or alternatives

Clinician name: Printed name and license

Order date: MM/DD/YYYY

Step-by-step: completing a POLST Full Code accurately

Follow these steps in order to document a POLST Full Code that is clinically actionable and easy to locate across care settings.

01

Confirm eligibility: Identify patients for whom POLST is appropriate after goals-of-care discussion.
02

Discuss options: Explain Full Code implications, likely outcomes, and alternatives to the patient or surrogate.
03

Complete form: Fill required fields, select Full Code, and note any clinical limitations or preferences.
04

Sign and distribute: Clinician and patient/surrogate sign, then place in chart and share copies as required.

Configuring an online POLST Full Code workflow

When using an electronic form, set up authentication, conditional fields, and routing to preserve clinical integrity and auditability.

Field	Configuration
Authentication	Email plus SMS code for clinician and surrogate verification
Conditional fields	Show advanced options only when 'Full Code' or other choices selected
Templates	Lock clinician-only fields to prevent edit by non-clinical staff
Audit trail	Enable timestamps, IP logging, and signer attribution

Where to file and who receives the completed POLST Full Code

A completed POLST should be recorded in the medical record and distributed to teams that respond to emergencies and transitions.

Electronic health record: Store the signed PDF in primary chart and problem list
Emergency services: Provide copy to EMS and include in advance directive registry where available
Patient or surrogate: Give a printed or electronic copy to the patient or decision-maker
Receiving facility: Send with patient on transfer and document receipt

Technical considerations for digital POLST Full Code completion

Ensure the signing platform supports secure authentication, audit trails, and formats accepted by clinical systems.

File formats: PDF/A or PDF with embedded signature
Integrations: EHR, EMS registry, and cloud storage
Security: TLS in transit and AES-256 at rest

Confirm compatibility with local health record systems and any state POLST registry before finalizing your electronic workflow to avoid acceptance issues.

Timing and review expectations for POLST Full Code orders

POLST orders should be timely and revisited when clinical status or patient preferences change. Document review intervals help keep orders current.

Effective date of order:

Order is effective on the clinician-specified date immediately upon signing

Review on transfer:

Reassess POLST at every transfer between care settings

Periodic review:

Recommend annual review or sooner for major health changes

Revocation timing:

Revocation takes effect when recorded and communicated to care teams

Registry submission:

If state registry exists, submit according to program rules

Common mistakes to avoid when preparing a POLST Full Code

Incomplete clinician signature or missing license number can render orders non-actionable in some institutions.
Selecting 'Full Code' without discussing likely outcomes may lead to interventions inconsistent with patient goals.
Failing to distribute copies to EMS and receiving facilities can cause delays or inappropriate withholding of care.
Using handwritten amendments without new signatures creates uncertainty about which version is authoritative.

Legal and clinical risks of an incorrect or incomplete POLST Full Code

Invalid orders: May be disregarded by clinicians

Care delays: Ambiguity can delay emergency treatment

Liability exposure: Clinician or facility risk if orders conflict with law

HIPAA breach: Improper sharing risks regulated privacy violations

Registry noncompliance: Failure to meet state rules may limit access

Patient harm: Incorrect orders can cause unwanted interventions

Comparing eSignature vendors for POLST Full Code workflows

Choose a signing platform that supports HIPAA controls, audit trails, and the required authentication for your jurisdiction; the table highlights common vendor differences.

	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	Trial available	Trial available	Trial available	Trial available
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently asked questions about POLST Full Code completion and use

Answers to common questions about legal validity, e-signing, revocation, and cross-setting recognition for POLST Full Code documents.

Need help? Contact support

Is a POLST Full Code legally binding?
A POLST records clinician orders and is intended to be followed as medical orders. Electronic execution is generally enforceable under the ESIGN Act (15 U.S.C. ch. 96) and state UETA statutes where adopted; verify state-specific POLST program rules.
Can the POLST be signed electronically?
Many states accept electronic signatures if the platform meets e-signature law requirements and institutional policy; confirm e-signature acceptance with the state POLST program and follow consumer-disclosure rules when applicable.
Who may sign a POLST Full Code?
A licensed clinician authorized to write medical orders signs the POLST; the patient or legally authorized surrogate documents consent. State programs may specify clinician types and surrogate authority.
How do I change or revoke a POLST?
Changes require a new clinician order and signatures; note the revocation in the medical record and notify EMS, receiving facilities, and any state registry to prevent conflicting orders.
Where should a completed POLST be stored?
Keep the signed form in the patient’s medical record, provide copies to the patient and surrogate, and submit to the state registry if available to improve access by EMS and other providers.
Will a POLST from another state be honored?
Receiving clinicians should generally follow valid medical orders, but acceptance can vary by state and facility; when crossing jurisdictions, clarify local acceptance and consider re-documentation if needed.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now