Medical Orders For Scope Of Treatment
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2HIPAA PERMITS DISCLOSURE OF MOST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
M O S T
Patient’s Last Name:
Effective Date of Form:
_________________
Medical Orders for Scope of Treatment
Form must be reviewed
at least annually.
This document is based on this person’s medical condition and wishes.
Patient’s First Name, Middle Initial:
Patient’s Date of Birth:
Any section not completed indicates a preference for full treatment for
that section.
Section
CARDIOPULMONARY RESUSCITATION (CPR): P
.
ERSON HAS NO PULSE AND IS NOT BREATHING
A
Attempt Resuscitation (CPR)
Do Not Attempt Resuscitation
Check One
When not in cardiopulmonary arrest, follow orders in B, C, and D.
Box Only
MEDICAL INTERVENTIONS: P
.
ERSON HAS PULSE OR IS BREATHING
Section
Full Scope of Treatment: Use intubation, advanced airway interventions, mechanical ventilation, defibrillation or
B
cardioversion as indicated, medical treatment, IV fluids, and provide comfort measures. Transfer to a hospital if indicated.
Includes intensive care. Treatment Plan: Full treatment including life support measures.
Limited Additional Intervention: Use medical treatment, oral and IV medications, IV fluids, cardiac monitoring as indicated,
Check One
non-invasive bi-level positive airway pressure, a bag valve mask, and comfort measures. Do not use intubation or mechanical
Box Only
ventilation. Transfer to hospital if indicated. Avoid intensive care. Treatment Plan: Provide basic medical treatments.
Comfort Measures: Keep clean, warm and dry. Use medication by any route. Positioning, wound care and other measures
to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort.
Do not transfer to hospital unless comfort needs cannot be met in the patient's current location (e.g. hip fracture).
________________________________________________________________________
Other Instructions
Section
ANTIBIOTICS
C
Antibiotics if indicated for the purpose of maintaining life
Other instructions:____________________________
Determine use or limitation of antibiotics when infection occurs.
__________________________________________
Check One
Use of antibiotics to relieve pain and discomfort.
__________________________________________
Box Only
No Antibiotics (use other measures to relieve symptoms).
MEDICALLY ADMINISTERED FLUIDS AND NUTRITION:
the provision of nutrition and fluids, even if medically
Section
administered, is a basic human right and authorization to deny or withdraw shall be limited to the patient, the surrogate in accordance with KRS
D
311.629, or the responsible party in accordance with KRS 311.631.
f
Long term
eeding tube if indicated
Check One
Long term IV fluids if indicated
Box Only in
Feeding tube for a defined trial period. Goal:______
IV fluids for a defined trial period. Goal:____________
Each
________________________________________________
_________________________________________________
Column
No feeding tube
No IV fluids (provide other measures to ensure comfort)
________________________________________________________________________
Special instructions
Section
Patient Preferences
s
Adult Patient with decisional capacity
pouse
E
as a Basis for
Parent/guardian of minor patient
Majority of patient’s reasonably available
This MOST Form:
adult children
Surrogate per advance directive
Check The
Parent
Judicially appointed guardian/durable power
Basis for order must be
Appropriate
of attorney with power to make health care
Majority of patient’s reasonably available
documented in medical
Box
record.
decisions
nearest living relatives of same relation
Directions were
Patient does not have an advance medical directive such as a living will or health care power of attorney.
given:
Patient has an advance medical directive such as a living will or health care power of attorney in place. I certify this form is in
Orally
accordance with the decisions in the current advance medical directive.
Written
Name: Printed: ___________________________ Position:______________ Signature:________________________________
I agree that adequate information has been provided and significant thought has been given to decisions outlined in this form. Treatment
preferences have been expressed to the physician (MD/DO). This document reflects those treatment preferences and indicates informed consent.
If signed by a patient, surrogate or responsible party, preferences expressed must reflect patient’s wishes as best understood by that surrogate or
responsible party. You are not required to sign this form to receive treatment.
Patient Surrogate or Responsible Party:
Signature:
Relationship:
Contact #:
Health Care Professional Preparing Form: Print Name
Health Care Professional Preparing Form: Signature
Preferred Phone #:
Date Prepared:
Physician Signature
Physician (Print Name)
Physician Contact Number
SEND FORM WITH PATIENT/RESIDENT WHEN TRANSFERRED OR DISCHARGED
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