Is an unsigned POLST valid?

An unsigned POLST is not an enforceable medical order. It may serve as a draft for discussion and documentation but requires the necessary clinician and patient or proxy signatures to become active orders; electronic evidence of consent and clinician attestation is required under ESIGN and applicable state law.

Can a POLST be signed electronically?

Yes — most states permit electronic signatures where ESIGN and UETA apply, and platforms that support secure audit trails, authentication, and HIPAA protections can capture legally binding signatures. Certain exceptions (testamentary documents) do not apply; confirm state POLST program rules.

Who must sign the POLST?

Signatures generally include the patient (or legally authorized representative) and a licensed clinician who can validate medical orders. State programs may specify clinician type (physician, NP, PA). If capacity is lacking, documented proxy authority must accompany the signature to ensure legal standing.

What are common preparation errors?

Common errors include incomplete clinical orders, ambiguous language, missing capacity assessments or proxy documentation, and failing to route forms to registries or the EMR. Each can invalidate orders, delay care transitions, or trigger legal review; accurate documentation and signatures prevent most issues.

How should unsigned forms be stored?

Store drafts in a secure, access‑controlled location separate from active medical orders. Use protected electronic folders with audit logs and versioning; apply HIPAA safeguards and retain draft metadata until signatures are obtained. Clearly label unsigned forms to avoid accidental clinical reliance.

When should a POLST be revised?

Revise POLST after major health status changes, hospitalizations, new prognostic information, or patient preference shifts. Document the clinical discussion, reassess decision‑making capacity, obtain new signatures, and update EMR and registries to ensure current orders guide future care.

Electronic Signature
Templates
Healthcare
Healthcare Unsigned POLST Form

Healthcare Unsigned POLST Form

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

HEALTHCARE POLST (Physician Orders for Life-Sustaining Treatment) — UNSIGNED

Patient Information

Patient Full Legal Name

Date of Birth

Gender

Medical Record #

Street Address

Primary Phone

Emergency Contact Name

Emergency Contact Phone

Primary Decision-Maker / Surrogate

Relationship to Patient

Decision-Maker Phone

Is Surrogate?

Yes

Facility / Clinician Information

Facility Name Facility Address

Clinician Name

Title

License / NPI #

Clinician Phone

Clinical Orders

Section A — Cardiopulmonary Resuscitation (CPR)

Select one: Attempt Resuscitation / Full CPR Do Not Attempt Resuscitation (DNR)

Medical directive: These selections are medical orders to be followed by health care professionals. If Attempt Resuscitation is selected, perform chest compressions, defibrillation, advanced airway as indicated. If DNR is selected, do not initiate chest compressions, advanced airway or electrical therapies.

Section B — Medical Interventions

Select the level of medical intervention appropriate to the patient’s goals and clinical condition:

Full Treatment — Use intubation, mechanical ventilation, and advanced hemodynamic support when indicated; transfer to hospital as needed. Selective/Intermediate Treatment — May include noninvasive ventilation, intravenous fluids and antibiotics; avoid intubation unless necessary for a short trial to reverse a reversible condition. Comfort-Focused Treatment — Emphasize symptom relief and comfort; avoid hospitalization and aggressive interventions unless required to relieve pain or suffering.

Antibiotics

Select one option regarding antibiotic use for infection:

Use antibiotics when indicated (route and duration per clinical judgment). Use antibiotics only to relieve symptoms (palliative intent). Do not use antibiotics to treat infection unless needed for comfort.

Antibiotic Instructions / Clarifications

Artificial Nutrition

Enter preferences for medically assisted nutrition:

Long-term tube feeding (consider PEG) if clinically appropriate. Trial period of tube feeding to assess benefit. Do not provide tube feeding; provide hand feeding and comfort measures only. Oral intake as tolerated; no artificial nutrition.

Nutrition Instructions / Clarifications

Other Orders / Clarifications

Use this space to document additional specific orders (e.g., dialysis preferences, IV fluids limits, palliative interventions, transfer instructions).

Goals of Care and Patient Preferences

Document the patient's expressed goals, values, and any statements about acceptable quality of life, trade-offs, or specific scenarios.

Review, Validity, and Legal Acknowledgment

These orders are intended to be actionable medical orders. They remain in effect until changed or revoked by the patient or the patient's authorized decision-maker, or until superseded by a subsequent valid POLST. Healthcare professionals are authorized to follow these orders as the patient's treatment preferences.

The patient has the right to revoke or amend this document at any time. If a surrogate or legal guardian signs on behalf of the patient, documentation of authority should be maintained in the medical record.

Planned Review Date

Form Completed At

Capacity Determination

Patient has decision-making capacity Patient lacks capacity; surrogate used

Acknowledgment

I acknowledge that the clinical orders selected on this POLST form have been discussed with me (or my authorized decision-maker). I understand these are medical orders intended to direct treatment across care settings and that I may revoke or amend these orders at any time. By signing below I attest that the selections reflect the patient's preferences or the known wishes of the patient when signing as an authorized surrogate.

Printed Name:

Relationship to Patient:

Signature:

Date:

What the Healthcare Unsigned POLST Form Is

The Healthcare Unsigned POLST Form is a physician‑endorsed medical orders document used to record a patient's preferences for life‑sustaining treatment, including CPR, intubation, antibiotics, and artificially administered nutrition. It is intended for patients with serious illness or frailty whose condition might lead to a medical emergency. Unlike advance directives, POLST translates preferences into actionable medical orders that travel with the patient across care settings. An 'unsigned' POLST refers to a completed form awaiting required clinician or patient signature, or one preserved in electronic systems before final authentication.

Why an Unsigned POLST Matters for Care Coordination

Use the Healthcare Unsigned POLST Form to prepare clear, portable medical orders that reflect a patient's current treatment preferences. Proper completion supports clinical decision making, reduces unwanted interventions, and aligns care across settings while remaining subject to ESIGN, UETA, and HIPAA rules for electronic records.

Teams and Roles That Handle Unsigned POLST Forms

Clinical teams, long‑term care staff, and emergency personnel commonly prepare or review the Healthcare Unsigned POLST Form before signatures are obtained.

Physicians and APRNs verifying medical orders during hospitalization and transitions of care.
Nursing facility staff documenting preadmission preferences and ensuring orders accompany transfers.
Emergency medical services using temporary unsigned forms to guide immediate prehospital interventions.

Family members, legal representatives, and care coordinators also interact with unsigned POLST forms to confirm preferences before formal signatures are obtained.

Primary Signers and Their Roles

Patient

The patient or legally authorized representative is the primary source of treatment preferences and may sign the POLST when competent. If the patient lacks capacity, the designated proxy or durable power of attorney for health care should sign following applicable state rules and documentation.

Clinician

A licensed clinician (physician, nurse practitioner, or physician assistant as state law permits) must review and co‑sign POLST entries that constitute medical orders; their signature attests to clinical discussion, medical appropriateness, and the accuracy of orders placed on the form.

Stepwise Preparation Before Signing

Follow these steps to prepare an unsigned POLST form ready for final clinician and patient signatures.

01

Gather Info: Collect diagnosis, prognosis, and advance directive details from chart.
02

Discuss Preferences: Have clinician lead a goals‑of‑care conversation with patient or proxy.
03

Complete Form: Enter orders, code status, and interpreter needs where applicable.
04

Prepare for Signature: Verify fields, attach supporting documents, and queue for signature.

Online Workflow Settings for Electronic POLST Handling

Configure an online workflow to collect, review, and store POLST forms securely while preserving clinical audit trails.

Form Field Configuration and Options	Defines how each form field behaves during signing.
Authentication Methods, Verification, and Strength	Email link, SMS code, or higher‑assurance KBA/SSO.
Routing Order and Signing Sequence	Define clinician first, then patient or proxy as signer.
Field Types and Conditional Logic	Use required, conditional, and read‑only fields for accuracy.
Storage Location and Retention Policy	Save signed copies to EMR, registry, with retention tags.

Technical Requirements for eSubmission Platforms

Ensure platform supports secure eSignature, HIPAA controls, and integration with electronic health records for reliable POLST handling.

File Formats: PDF and DOCX export/import supported
Integrations: Connectors for EMR, Box, Google Drive
Authentication Options: Email, SMS, SSO available

How Unsigned POLST Moves Through the Care Workflow

Unsigned POLST workflows move from documentation to clinical review, authorization, and distribution across care settings.

Document: Complete order fields and attach relevant clinical notes.
Review: Clinician reviews decisions for medical appropriateness.
Authorize: Clinician and patient/proxy sign to activate orders.
Share: Distribute signed copy to registry, EMR, and caregivers.

Security and Privacy Essentials

Encryption: TLS 1.2/1.3 in transit; AES‑256 at rest

Access Controls: Role‑based permissions and audit logging

Audit Trail: Comprehensive timestamps, IP, and action log

BAA Required: Signed Business Associate Agreement available

Authentication: Email, SMS, optional KBA or SSO

Data Formats: PDF, DOCX, and structured XML

Timing and Review Expectations

POLST forms should be reviewed and updated when clinical status or care settings change to ensure orders remain current.

When to Complete the Initial POLST:

Complete at point of serious illness discussion or anticipated clinical decline.

Review Upon Transfer Between Care Settings:

Review and sign updates when patient moves between facility types.

Document Update After Major Clinical Change:

Reassess goals of care and amend orders within clinically appropriate timeframe.

Submit to State POLST Registry Promptly:

Upload signed forms to state registries where available, ideally same day.

Periodic Review Frequency Recommended by Facilities:

Facilities commonly review annually or whenever clinical condition changes.

Common Preparation and Documentation Errors

Leaving the signature block blank without clear next‑step instructions can create delays in activating physician orders and lead to inconsistent treatment across care settings.
Using ambiguous language such as 'consider' or 'as appropriate' rather than explicit orders makes the POLST unusable in emergencies and increases clinical uncertainty.
Failing to document decision‑making capacity or proxy authority can invalidate a signature and require re‑consent, complicating urgent care and legal review.
Storing unsigned or partially completed forms only in local paper charts instead of EMR and registries risks loss during transfers and impedes emergency access.

Consequences of an Incorrect or Incomplete POLST

Invalid Orders: May be disregarded by clinicians

Clinical Delays: Treatment may be postponed

Legal Disputes: Potential for surrogate challenges

HIPAA Exposures: Improper storage could trigger fines

Billing Complications: Orders misapplied affect billing

Registry Rejection: Incomplete data may be rejected

Comparing eSignature Plans for POLST Workflows

Compare common eSignature plan features and starting prices relevant to submitting POLST forms electronically and meeting healthcare compliance.

	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 trial	Varies	Varies	Varies	Varies
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

How to Update or Revise an Existing POLST

When revising a POLST, follow a documented clinical workflow to update orders, obtain new signatures, and record versions in the medical record.

01

Identify Need:

Note clinical changes prompting amendment.

02

Reassess Patient:

Conduct goals‑of‑care conversation with patient or proxy.

03

Update Orders:

Edit medical interventions and code status as agreed.

04

Obtain Signatures:

Clinician and patient/proxy must sign new version.

05

Document Rationale:

Record clinical reasons and decision capacity findings.

06

Distribute Copies:

Upload to EMR and any state registry; notify team.

Frequently Asked Questions About Unsigned POLST Forms

Answers to common questions about preparing, validating, and managing unsigned POLST forms, with focus on legal validity, signatures, and electronic handling.

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