A B C D - The Indiana Post Program
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INDIANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (POST)
State Form 55317 (R2 / 12-16)
Indiana State Department of Health – IC 16-36-6
INSTRUCTIONS: This form is a physician’s order for scope of treatment based on the patient’s current medical condition
and preferences. The POST should be reviewed whenever the patient’s condition changes. A POST form is voluntary. A
patient is not required to complete a POST form. A patient with capacity or their legal representative may void a POST
form at any time by communicating that intent to the health care provider. Any section not completed does not invalidate
the form and implies full treatment for that section. HIPAA permits disclosure to health care professionals as necessary
for treatment. The original form is personal property of the patient. A facsimile, paper, or electronic copy of this form
is a valid form.
Patient Last Name
Patient First Name
Middle Initial
Birth Date (mm/dd/yyyy)
Medical Record Number
Date Prepared (mm/dd/yyyy)
D
P
’
P
:
The following sections (A through D) are the patient’s current
ESIGNATION OF
ATIENT
S
REFERENCES
preferences for scope of treatment.
C
R
(CPR):
Patient has no pulse AND is not breathing
ARDIOPULMONARY
ESUSCITATION
A
Attempt Resuscitation/CPR
Do Not Attempt Resuscitation/DNR
Check
When not in cardiopulmonary arrest, follow orders in B, C and D
One
M
I
:
If patient has pulse AND is breathing OR has pulse and is NOT breathing
EDICAL
NTERVENTIONS
B
Comfort Measures (Allow Natural Death): Treatment Goal: Maximize comfort through symptom management.
Check
Relieve pain and suffering through the use of any medication by any route, positioning, wound care and other
One
measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Patient
prefers no transfer to hospital for life-sustaining treatments. Transfer to hospital only if comfort needs cannot
be met in current location.
Limited Additional Interventions: Treatment Goal: Stabilization of medical condition. In addition to care
described in Comfort Measures above,
use medical treatment for
stabilization, IV fluids (hydration) and
cardiac monitor as indicated to stabilize medical condition.
May use basic airway management techniques
and non-invasive positive-airway pressure. Do not intubate. Transfer to hospital if indicated to manage
medical needs or comfort. Avoid intensive care if possible.
Full Intervention: Treatment Goal: Full interventions including life support measures in the intensive care unit.
In addition to care described in Comfort Measures and Limited Additional Interventions above, use intubation,
advanced airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive
care unit if indicated to meet medical needs.
A
:
C
NTIBIOTICS
Use antibiotics for infection only if comfort cannot be achieved fully through other means.
Check
Use antibiotics consistent with treatment goals.
One
D
A
A
N
: Always offer food and fluid by mouth if feasible.
RTIFICIALLY
DMINISTERED
UTRITION
No artificial nutrition.
Check
Defined trial period of artificial nutrition by tube.
(Length of trial: ________ Goal: ______________________)
One
Long-term artificial nutrition.
O
A
O
:
PTIONAL
DDITIONAL
RDERS
S
P
:
This form consists of two (2) pages. Both pages must be present. The following page
IGNATURE
AGE
includes signatures required for the POST form to be effective.
Page 1 of 2
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