Who can sign a POLST update?

A licensed ordering clinician must sign to create a valid medical order; the patient or a legally authorized surrogate must also sign when required by the state or program.

Can a POLST be signed electronically?

Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; verify state POLST program rules and use HIPAA-compliant eSignature workflows when PHI is involved.

How do I correct an error on a signed POLST?

Do not alter a signed form. Create a new update form noting prior version superseded, obtain required signatures, and distribute the corrected copy to all holders.

Is POLST legally binding?

POLST is a medical order intended to be followed by clinicians and EMS; its legal weight depends on state program rules and proper clinician and patient/surrogate authorization.

What if the patient loses decision-making capacity?

If capacity changes, the surrogate or agent authorized under state law may confirm or request updates consistent with prior patient preferences and legal authority.

How long is an updated POLST valid?

Validity depends on the orders and clinical context; many programs recommend routine review at least annually or after major health changes and immediate reissue if goals change.

Electronic Signature
Templates
Healthcare
Healthcare POLST Update Form

Healthcare POLST Update Form

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Healthcare POLST Update Form

Patient Information

Patient Name

Date of Birth: Gender: Male Female Other

Address Primary Phone

Emergency Contact

Contact Name Relationship Contact Phone

Insurance & Identification

Insurance Provider Policy / ID Number Subscriber Name

Medical History

Current Medications Allergies Prior Surgeries / Hospitalizations Chronic Conditions

POLST Orders — Update

Cardiopulmonary Resuscitation (CPR): Attempt Resuscitation (Attempt CPR) Do Not Attempt Resuscitation (DNR)

Medical Interventions (select one):

Intervention Preference Full Treatment — use all medically indicated life-sustaining treatments including intubation and advanced airway management Selective Treatment — hospitalization and selected interventions; avoid intubation unless reversible and likely to restore acceptable quality of life Comfort-Focused Treatment — focus on relief of pain and symptoms; avoid hospitalization and aggressive interventions

Intubation / Mechanical Ventilation: Allow intubation if needed Do not intubate

Antibiotics:

Use antibiotics if indicated Use antibiotics limited to comfort or limited courses Do not use antibiotics

Artificial Nutrition:

Long-term artificial nutrition by feeding tube Limited trial of artificial nutrition No artificial nutrition Other Orders / Limitations

Update Details & Authorization

Reason for update:

This update supersedes and replaces prior POLST dated:

Summary of Discussion (who participated, key points discussed, patient's goals)

Patient retains the right to revoke or amend these orders at any time. These orders are medical orders intended to guide emergency personnel and treating clinicians across care settings and should be honored unless inconsistent with clinical circumstances or later valid orders.

Review / Expiration

This POLST update should be reviewed no later than:

Patient / Surrogate Acknowledgment

The patient or authorized surrogate confirms that the orders above reflect the patient’s current preferences and that risks, benefits, and alternatives have been discussed. By signing below the individual acknowledges understanding that these are physician orders to be followed by health care professionals.

If signed by surrogate, indicate authority Name of Person Providing Consent (if not patient)

Clinician Attestation

I attest that I have discussed the patient's medical condition, prognosis, treatment options, and the benefits and burdens of life-sustaining treatments as applicable. I confirm that the orders above reflect the informed preferences of the patient or the patient's authorized surrogate. I have assessed the patient's decision-making capacity and documented findings in the medical record.

Clinician Name License / DEA / Credential Clinical Affiliation / Facility Clinician Signature Clinician Signature Date

Distribution: A copy of this updated POLST should be kept with the patient's medical record, provided to the patient or surrogate, and made available to emergency responders and receiving facilities. These orders remain in effect until amended or revoked in writing by the patient or their authorized representative or by subsequent valid medical orders.

Privacy & Acknowledgment

I acknowledge that my health information relevant to the implementation of these orders may be shared among treating providers and emergency personnel as necessary to carry out care consistent with these orders.

I acknowledge and consent to the sharing of necessary health information for implementation of these orders.

Patient / Surrogate Printed Name:

Relationship (if signed by surrogate):

By:

Date:

What the Healthcare POLST Update Form Is

The Healthcare POLST Update Form documents changes to a patient's Physician Orders for Life-Sustaining Treatment (POLST). It updates medical orders about CPR, intubation, antibiotics, and feeding tubes so clinicians, emergency responders, and care facilities follow current patient preferences. The form is a clinician-verified medical order rather than a living will and is typically completed with the patient or their authorized surrogate. State programs and registries vary; copies should be placed in the medical record and provided to EMS, the patient, and designated caregivers.

Why Keeping POLST Records Current Matters

An updated POLST ensures treatment aligns with the patient’s current goals, reduces unwanted interventions, and clarifies clinician orders during emergencies and care transitions.

Who Typically Completes or Reviews a POLST Update

POLST updates involve the patient, clinical team, and sometimes a legally authorized representative; they are an interdisciplinary effort to document medical orders.

Patients with advanced illness or frailty who wish to record current treatment preferences for emergencies.
Primary clinicians (physicians, nurse practitioners, physician assistants) who must translate preferences into medical orders.
Caregivers, nursing facility staff, and EMS personnel who need an accessible copy of orders during transport or handoffs.

Clear roles and distribution after signing help ensure the updated orders are followed across settings.

Key Roles and Who Signs

Primary Patient

The patient initiates updates when goals or health status change. If capacity is impaired, a legally authorized surrogate provides direction consistent with state law and prior known wishes.

Clinician/Provider

A licensed clinician converts patient preferences into physician orders, documents clinical indications, and signs the POLST. The clinician confirms understanding and capacity or surrogate authority.

Essential Elements of a Professional POLST Update Form

A well-constructed POLST update contains identifiable patient data, explicit treatment orders, signatures and dates, and clear instructions for EMS and facility staff.

Patient Identification

Full legal name, date of birth, and a medical record or identifier ensure the updated orders attach correctly to the patient file and avoid misapplication.

Treatment Sections

Discrete sections for CPR, medical interventions, antibiotics, and artificial nutrition let clinicians record precise choices and limit ambiguity during urgent decisions.

Clinical Indication

A brief clinical note or diagnosis provides context for the orders and supports clinician judgment when applying the POLST across settings.

Signatures and Dates

Signature blocks for the patient or surrogate and the ordering clinician with dates establish the document’s authority and the effective timing of the updated orders.

Distribution Instructions

Instructions for giving copies to EMS, the medical record, and any state registry ensure the updated POLST is accessible where care decisions occur.

Review and Expiration

A recommended review interval and space for notation of future reviews or expiration reduces stale or outdated orders and prompts periodic reassessment.

Step-by-Step: Updating a POLST

Follow this sequence to create a valid, distributed update that clinicians and first responders can act on immediately.

01

Confirm Capacity: Assess patient decision-making capacity or document surrogate authority before changing orders.
02

Discuss Options: Review goals of care, prognosis, and specific interventions with patient or surrogate.
03

Complete Form: Fill all required fields, choose standardized options, and add clinical context as needed.
04

Sign and Distribute: Obtain required signatures, file in the record, and provide copies to EMS and caregivers.

Common Operational Steps for Electronic POLST Updates

Operational controls help teams complete and track POLST updates in electronic workflows.

01

Identify Patient:

Confirm identity before editing or saving.

02

Apply Changes:

Use tracked edits for auditability.

03

Authenticate Signer:

Use appropriate signer authentication based on risk.

04

Timestamp Record:

Record exact date/time of clinician order.

05

Version Control:

Retain prior form versions with change log.

06

Notify Stakeholders:

Send copies to EMS, facility staff, and family.

Configuring an Online POLST Update Workflow

Set up form fields, authentication, storage, and notifications to support compliant electronic updates.

Field	Configuration
Required Fields	Make patient ID and clinician signature mandatory.
Conditional Logic	Show surrogate fields only if capacity is lacking.
Authentication	Include multi-factor or SMS code for clinician signers.
Notifications	Email copies to EMS and designated caregivers automatically.

Technical and Distribution Considerations

Choose a platform that supports PDF/DOCX import, audit trails, secure storage, and HIPAA controls for patient data.

File Formats: Supports PDF, DOCX, and image attachments.
Integrations: Works with EHRs and cloud storage platforms.
Authentication: Options include email, SMS code, and stronger methods.

Where an Updated POLST Should Be Filed or Sent

Ensure copies of the updated POLST are placed in systems and locations where care decisions are made.

Medical Record: Scan or attach the signed POLST in the patient’s EHR chart for clinician access.
State Registry: Where available, register the updated POLST in the state or regional registry for EMS access.
EMS Copy: Provide a portable copy (paper or digital) for first responders during transport.
Family/Caregiver: Give a dated copy to the patient and designated caregivers to present during emergencies.

Required Data Points for the POLST Update

Patient Name: Full legal name

Date of Birth: MM/DD/YYYY

MRN / ID: Facility medical record number

Treatment Orders: CPR and intervention choices

Surrogate Info: Name and relationship

Signatures: Patient/surrogate and clinician

Timing, Review Intervals, and Processing Expectations

Key timing points affect when an update takes effect and when stakeholders should receive the revised order.

Effective Date:

Order becomes effective on the clinician-specified date or upon signing if indicated.

Immediate Distribution:

Provide a copy to EMS and the medical record immediately after signing.

Registry Filing:

Where registries exist, submit promptly to ensure EMS can access the update.

Periodic Review:

Recommend formal review at least annually or after major health changes.

Notarization:

Notarization is rarely required for POLST; follow state program guidance if specified.

Common Mistakes When Preparing a POLST Update

Failing to confirm patient capacity or document surrogate authority leads to legal and clinical disputes.
Leaving treatment choices ambiguous or using inconsistent language can cause conflicting interpretations in emergencies.
Not distributing the updated form to EMS, the chart, and caregivers creates a high risk that outdated orders are followed.
Omitting the clinician’s dated signature or using unclear witness information can render the order non-actionable.

Risks from an Incorrect or Incomplete POLST Update

Invalid Orders: Orders may be unenforceable

Delayed Care: Treatment hesitation or inappropriate care

Legal Disputes: Potential litigation or surrogate challenges

Billing Issues: Incorrect billing for provided services

EMS Noncompliance: First responders may follow prior orders

Privacy Breach: HIPAA violations and penalties

Comparing eSignature Platforms for POLST Updates

Use an eSignature solution that supports HIPAA controls, audit trails, and EHR integration. The table compares common vendor attributes and starting prices.

	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, no card	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Frequently Asked Questions About POLST Updates

Answers to common questions about who can sign, e-signature legality, corrections, and distribution for POLST updates in the United States.

Need help? Contact support

Who can sign a POLST update?
A licensed ordering clinician must sign to create a valid medical order; the patient or a legally authorized surrogate must also sign when required by the state or program.
Can a POLST be signed electronically?
Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted; verify state POLST program rules and use HIPAA-compliant eSignature workflows when PHI is involved.
How do I correct an error on a signed POLST?
Do not alter a signed form. Create a new update form noting prior version superseded, obtain required signatures, and distribute the corrected copy to all holders.
Is POLST legally binding?
POLST is a medical order intended to be followed by clinicians and EMS; its legal weight depends on state program rules and proper clinician and patient/surrogate authorization.
What if the patient loses decision-making capacity?
If capacity changes, the surrogate or agent authorized under state law may confirm or request updates consistent with prior patient preferences and legal authority.
How long is an updated POLST valid?
Validity depends on the orders and clinical context; many programs recommend routine review at least annually or after major health changes and immediate reissue if goals change.

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