Iowa Physician Orders Form For Scope Of Treatment (Ipost)
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1
2HIPAA PERMITS DISCLOSURE OF IPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Last Name
Iowa Physician Orders
for Scope of Treatment
(IPOST)
First follow these orders, THEN contact the physician,
First/Middle Name
nurse practitioner or physician’s assistant. This is a
medical order sheet based on the person’s current
medical condition and treatment preferences. Any
section not completed implies full treatment for that
Date of Birth
section. Everyone shall be treated with dignity and
respect.
A
C
R
(CPR):
Person has no pulse AND is not breathing.
ARDIOPULMONARY
ESUSCITATION
Check
CPR/Attempt Resuscitation
one
DNR/Do Not Attempt Resuscitation
B
MEDICAL INTERVENTIONS:
Person has a pulse AND/OR is breathing.
COMFORT MEASURES ONLY Use medication by any route, positioning, wound care and
other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of
Check
airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-
one
sustaining treatment. Transfer if comfort needs cannot be met in current location.
LIMITED ADDITIONAL INTERVENTIONS Includes care described above. Use medical
treatment, cardiac monitor, oral/IV fluids and medications as indicated. Do not use intubation,
or mechanical ventilation. May consider less invasive airway support (BiPAP, CPAP). May use
vasopressors. Transfer to hospital if indicated, may include critical care.
FULL TREATMENT Includes care described above. Use intubation, advanced airway
interventions, mechanical ventilation and cardioversion as indicated. Transfer to hospital if
indicated. Includes critical care.
Additional Orders: ________________________________________________________
C
ARTIFICIALLY ADMINISTERED NUTRITION
Always offer food by mouth if feasible.
No artificial nutrition by tube.
Check
Defined trial period of artificial nutrition by tube.
one
Long-term artificial nutrition by tube.
D
MEDICAL DECISION MAKING
Directed by:
Rationale for these orders:
(listed in order of Iowa Code/Statute for
(check all
Priority of Surrogates; check only one)
that apply)
Patient
Advance Directives
Durable Power of Attorney for Health Care
Patient’s known preference
Spouse
Limited treatment options
Majority of Adult Children
Poor prognosis
Parents
Other: ________________________
Majority rule for nearest relative
Other: ____________________________
Physician/ARNP/PA signature
Print Physician/ARNP/PA Name
Date
Phone Number
(mandatory)
Patient/Resident or Legal Surrogate for Health Care Signature as identified above
Date
(mandatory)
SEND IPOST WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
DOCUMENT THAT IPOST FORM WAS TRANSFERRED WITH PERSON
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