Dnr/colst Clinician Orders For Dnr/cpr And Other Life Sustaining Treatment Page 4
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4HIPAA PERMITS DISCLOSURE OF COLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
H
Informed Consent and Clinician Signature for COLST Order (Sections B through G)
Informed Consent for this COLST Order has been obtained from:
______________________________________________________
__________________________________
Name of Person Giving Informed Consent
Relationship to Patient
(Patient if competent)
(Write “self” if Patient)
___________________________________________________________________
Signature
Clinician Signature for COLST
__________________________________________
______________________________________
Signature of Clinician
Printed Name of Clinician
Dated:_________________________________________
Print Clinician Name
Clinician Signature (mandatory)
Phone Number
Person providing consent’s signature (if available)
Date
Other Contact Information (Optional)
Name of Guardian, Agent or other Contact Person
Relationship
Phone Number
Name of Health Care Professional Preparing Form
Preparer Title/Facility
Phone Number
Date Prepared
Review Date
Reviewer
Location of Review
Review Outcome
No Change
New form
completed
Form Voided
No Change
New form
completed
Form Voided
No Change
New form
completed
Form Voided
SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED
GIVE COPY TO PATIENT AND REPRESENTATIVE
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Parent category: Medical