Medical Orders For Scope Of Treatment Page 2

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INFORMATION FOR PATIENT
SURROGATE OR RESPONSIBLE PARTY OF PATIENT NAMED ON THIS FORM
The MOST form is always voluntary and is usually for persons with advanced illness. MOST records your wishes for medical
treatment in your current state of health. The provision of nutrition and fluids, even if medically administered, is a basic
human right and authorization to deny or withdraw shall be limited to the patient, the surrogate in accordance with KRS
311.629, or the responsible party in accordance with KRS 311.631. Once initial medical treatment is begun and the risks and
benefits of further therapy are clear, your treatment wishes may change. Your medical care and this form can be changed to
reflect your new wishes at any time. However, no form can address all the medical treatment decisions that may need to be
made. An advance directive, such as the Kentucky Health Care Power of Attorney, is recommended for all capable adults,
regardless of their health status. An advance directive allows you to document in detail your future health care instructions or
name a surrogate to speak for you if you are unable to speak for yourself, or both. If there are conflicting directions between
an enforceable living will and a MOST form, the provisions of the living will shall prevail.
DIRECTIONS FOR COMPLETING AND IMPLEMENTING FORM
C
MOST
OMPLETING
MOST must be reviewed, prepared and signed by the patient’s physician in personal communication with the
patient, the patient’s surrogate or responsible party.
MOST must be reviewed and contain the original signature of the patient’s physician to be valid. Be sure to
document the basis in the progress notes of the medical record. Mode of communication (e.g., in person, by
telephone, etc.) should also be documented.
The signature of the patient, surrogate or a responsible party is required; however, if the patient’s surrogate or a
responsible party is not reasonably available to sign the original form, a copy of the completed form with the
signature of the patient’s surrogate or a responsible party must be signed by the patient’s physician and placed in
the medical record.
Use of original form is required. Be sure to send the original form with the patient.
There is no requirement that a patient have a MOST.
I
MPLEMENTING MOST
• If a health care provider or facility cannot comply with the orders due to policy or personal ethics, the provider or
facility must arrange for transfer of the patient to another provider or facility.
R
MOST
EVIEWING
This MOST must be reviewed at least annually or earlier if:
• The patient is admitted and/or discharged from a health care facility;
• There is a substantial change in the patient’s health status; or
• The patient’s treatment preferences change.
• If MOST is revised or becomes invalid, draw a line through sections A – E and write “VOID” in large letters.
R
MOST
EVOCATION OF
This MOST may be revoked by the patient, the surrogate or the responsible party.
Review of MOST
Review Date
Reviewer and Location
MD/DO Signature (Required)
Signature of Patient, Surrogate
Outcome of Review, describing
of Review
or Responsible Party
the outcome in each row by
(Required)
selecting one of the following:
 No Change
 FORM VOIDED, new form completed
 FORM VOIDED, no new form
 No Change
 FORM VOIDED, new form completed
 FORM VOIDED, no new form
SEND FORM WITH PATIENT/RESIDENT WHEN TRANSFERRED OR DISCHARGED

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