Patient Orders for Life Sustaining Treatment (POLST)

Advanced care planning discussion was voluntary and an option to decline was given.

This service was performed because of a change in patient status or as part of a routine annual wellness exam.

Total time spent discussing advanced care directives today: [text name="time" default="16 minutes"].

I explained advanced care directives, the role of power of attorney for healthcare, and the patient's prognosis.

Individuals present for the discussion:
[text name="individuals_present" default="Patient's power of attorney"]

Healthcare power of attorney name: [text name="POA" default="POA Name"]

Healthcare power of attorney phone number: [text name="POA_phone" default="POA Phone Number"]

A. CODE STATUS if the patient has no pulse and is not breathing.

[select name="Code_status" value="YES CPR: Attempt Resuscitation, including mechanical ventilation, defibrillation and cardioversion. (Requires choosing Full Treatments in Section B)|NO CPR: Do Not Attempt Resuscitation. (May choose any option in Section B)"]

B.Initial Treatment Recommendation if the patient has a pulse and/or is breathing.

[select name="Initial_Treatment" value="Full Treatments (required if choose CPR in Section A). Goal: Attempt to sustain life by all medically effective means. Provide appropriate medical and surgical treatments as indicated to attempt to prolong life, including intensive care.|Selective Treatments. Goal: Attempt to restore function while avoiding intensive care and resuscitation efforts (ventilator, defibrillation and cardioversion). May use non-invasive positive airway pressure, antibiotics and IV fluids as indicated. Avoid intensive care. Transfer to hospital if treatment needs cannot be met in current location.|Comfort-focused Treatments. Goal: Maximize comfort through symptom management; allow natural death. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Avoid treatments listed in full or select treatments unless consistent with comfort goal. Transfer to hospital only if comfort cannot be achieved in current setting."]

C. Additional Recommendations (e.g., blood products, dialysis, surgery)

[textarea name="Addl_Rx" default="Use this space to clarify any preferences on specific treatments"]

D.Medically Assisted Nutrition (Offer food by mouth if desired by patient, safe and tolerated)

[select name="Nutrition" value="Provide feeding through new or existing surgically-placed tubes|Trial period for artificial nutrition but no surgically-placed tubes|No artificial means of nutrition desired"]
Advanced care planning discussion was voluntary and an option to decline was given.

This service was performed because of a change in patient status or as part of a routine annual wellness exam.

Total time spent discussing advanced care directives today: .

I explained advanced care directives, the role of power of attorney for healthcare, and the patient's prognosis.

Individuals present for the discussion:


Healthcare power of attorney name:

Healthcare power of attorney phone number:

A. CODE STATUS if the patient has no pulse and is not breathing.



B.Initial Treatment Recommendation if the patient has a pulse and/or is breathing.



C. Additional Recommendations (e.g., blood products, dialysis, surgery)



D.Medically Assisted Nutrition (Offer food by mouth if desired by patient, safe and tolerated)

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.38, 8 form elements, 125 boilerplate words, 4 text boxes, 1 text areas, 3 drop downs, 8 total clicks
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