Please Credit Jane Dinnen, RN, Munson Medical Center
MICHIGAN POLST CHART REVIEW DATA COLLECTION FORM
1. Is a POLST form present? q Yes q No
If yes, describe: q original pink form q photocopy q fax q other
2. Where is the form located? q Front of chart q Protective sleeve q MD Orders
q special AD section q other ______
3. Which version of the form is being used? q Original q ______
4. Resident month and year of birth: ____month ___ year
5. Resuscitation orders: q Resuscitate q Do Not Resuscitate q blank
6. Medical Interventions: q Comfort Measures Only q Limited Interventions
q Full Treatment q blank
7. Are additional orders provided about medical interventions? q Yes q No
If so, what:______
8. Antibiotics: q No antibiotics q Determine use of limitation of antibiotics when infection occurs
q Use antibiotics if life can be prolonged q blank
9. Are additional orders provided about antibiotics? q Yes q No
If so, what: ______
10. Artificially administered fluids and nutrition:
q No artificial nutrition by tube q Defined trial period
q Long term artificial nutrition by tube q blank
11. Are additional orders provided about artificially administered fluids and nutrition? q Yes q No
If so, what: ______
12. Discussed with: q Patient q health care representative
q court-appointed guardian q parent of minor q other______q blank
13. Is anything written in the sections requesting the basis for orders/medical condition information?
q yes (If yes, check below all that apply to the orders) q no
q patient wishes q specific medical diagnosis q physician orders
q vague medical information q other ______
14. Signature line contains:
q physician signature ______q nurse practitioner signature ______q no signature
(date signed) (date signed)
q other health care provider signature q patient/surrogate signature
15. Is there a phone number for the physician/nurse practitioner? q yes q no
16. Has the form been modified in any way? q yes q no
If so, how? q bar code q organizational logo q words crossed out q patient identifier
q other______
17. Does the POLST form contain a patient/resident/surrogate signature? q yes q no
18. Has the POLST form ever been reviewed? q yes ______times q no
If yes, what was the outcome of the most recent review?
q no change q voided/new form completed q voided/no new form
19. Who prepared the POLST form? q staff member q MD/NP q family member
q patient/resident q unknown person______q blank
20. Did the person have an advance directive? q yes q no q blank
21. Did the person have a court-appointed guardian? q yes q no q blank
22. Other issues noted: ______
______
______