Medical Orders For Scope Of Treatment (Page 2 of 3) in pdf

DIRECTIONS FOR HEALTH CARE PROFESSIONALS

COMPLETING A DMOST FORM

• Must be signed by a Licensed Physician, Advance Practice Registered Nurse, or Physician Assistant.

• Use of original form is highly encouraged. Photocopies and faxes of signed DMOST forms are legal and valid.

• Any incomplete section of a DMOST form indicates the patient should get the full treatment described in that section.

REVIEWING A DMOST FORM

-- It is recommended that a DMOST form be reviewed periodically, especially when:

• The patient is transferred from one care setting or care level to another,

• There is a substantial change in the patient’s health status, or

• The patient’s treatment preferences change.

MODIFYING AND VOIDING INFORMATION ON A COMPLETED DMOST FORM

A patient with decision-making capacity can void a DMOST form at any time in any manner that indicates an intent to void.

Any modification to the form voids the DMOST form. A new DMOST form may be completed with a health care practitioner.

Forms are available online at

SECTION A

This section outlines the specific goals that the patient is trying to achieve by this treatment plan. Health care

professionals shall share information regarding prognosis with the patient in order to assist the patient in setting achievable goals.

Examples may include:

• Longevity, cure, remission or better quality of life

• To live long enough to attend an important event (wedding, birthday, graduation)

• To live without pain, nausea, shortness of breath or other symptoms

• Eating, driving, gardening, enjoying time with family, or other activities

SECTION B

This is a medical order. Mark a selection for the patient’s preferences regarding CPR.

SECTION C

This is a medical order. When “limited treatment” is selected, also indicate whether the patient prefers or does not prefer

transfer to a hospital for additional care.

• IV medication to enhance comfort may be appropriate treatment for a patient who has indicated “symptom treatment only.”

• Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP) and bi-level positive airway pressure

(Bi-PAP).

• The patient will always be provided with comfort measures.

• Patients who are already receiving long-term mechanical ventilation may indicate treatment limitations on the “Other Orders” line.

SECTION D

This is medical order. Mark a selection for the patient’s preferences regarding nutrition and hydration. Check one box.

• Oral fluids and nutrition should always be offered if feasible and consistent with the goals of care.

SECTION E

This section documents with whom the medical orders were discussed, the name of any health care professional who

assisted in the completion of the Form, the name of any authorized representative and if the authorized representative may not modify/

void the form.

SECTION F

To be valid, all information in this section must be completed.

HIPAA PERMITS DISCLOSURE OF DMOST TO OTHER HEALTH CARE

PROFESSIONALS AS NECESSARY FOR TREATMENT.

SEND FORM WITH PATIENT WHENEVER MOVED TO A NEW SETTING

Faxed, Copied, or Electronic Versions of the Form are legal and valid.

Medical Orders For Scope Of Treatment Page 2

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