Medical Orders For Scope Of Treatment
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1
2HIPAA PERMITS DISCLOSURE OF MOST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Medical Orders
Patient’s Last Name:
Effective Date of Form:
___________________
for Scope of Treatment (MOST)
Form must be reviewed
at least annually.
This is a Physician Order Sheet based on the person’s medical
Patient’s First Name, Middle Initial:
Patient’s Date of Birth:
condition and wishes. Any section not completed indicates full
treatment for that section. When the need occurs, first follow
these orders, then contact physician.
Section
CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.
A
Attempt Resuscitation (CPR)
Do Not Attempt Resuscitation (DNR/no CPR)
Check One
Box Only
When not in cardiopulmonary arrest, follow orders in B, C, and D.
Section
MEDICAL INTERVENTIONS: Person has pulse and/or is breathing.
B
Full Scope of Treatment:
Use intubation, advanced airway interventions, mechanical ventilation, cardioversion as
indicated, medical treatment, IV fluids, etc.; also provide comfort measures. Transfer to hospital if indicated.
Limited Additional Interventions:
Use medical treatment, IV fluids and cardiac monitoring as indicated.
Check One
Do not use intubation or mechanical ventilation; also provide comfort measures. Transfer to hospital if indicated.
Box Only
.
Avoid intensive care.
.
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 current location.
Other Instructions
Section
ANTIBIOTICS
Antibiotics if life can be prolonged.
C
Determine use or limitation of antibiotics when infection occurs.
No Antibiotics (use other measures to relieve symptoms).
Check One
Other Instructions
Box Only
Section
MEDICALLY ADMINISTERED FLUIDS AND NUTRITION: Offer oral fluids and nutrition if
T
T
R R
R
R R R T T
I I
I I
I I O O
O O
O O
O O
O O N N
N N
N N
N N
N N : :
Offer ora ra
O
Offer
Offer
ral
ral
ra ra
al f
al f
al al
l f l f
fluids and
physically feasible.
D
IV fluids long-term if indicated
Feeding tube long-term if indicated
F F ee eed d i i n n g g
g g
g g tub
tu
t t
t t
t t
be
e
l
l
o
o
n
n
g
g t t
-t t
- er er
er er
er er
e e r r r r
m
m m
m m
if indicated
Check One
IV fluids for a defined trial period
Feeding tube for a defined trial period
F F ee eed d i i n n g g ub
tu tu
tu tu e
ub
ub
ub
ub
ub
e
f
f f
f f
f f
o
o
r
r
a
a
d
d e e
e e
f f
f f
f f
f f
f f f f
f f f f f f f f
i i
i i i i
n n
n n
e
e e
e e
d trial period
Box Only in
No IV fluids (provide other measures to ensure comfort)
o en
n
n s
s
s s
u u
u u u u r r
r r u u u u
e e c c o o m m f f or or
f f f f t t r r r ) ) t
No feeding tube
No o f f ee ee
f f f f d d
ee ee
ee ee ee ee
d d
d d i i
i i
i i n n
n n
n n g g
g g
g g t t
t t
t t
t t
t t ub
u
u u
u u e
Each
Other Instructions
Column
DISCUSSED WITH
Section E
Majority of patient’s reasonably available
M
M
M a
a
a j j
a o o
j j j
o o o o o
r r
r r
it it
it
ity y
t t t t
t t
y y y y y y
of of p p
f f
f f
f f
p p
a a
a a
ti ti a a a a
ti ti
e e n n t t ’ ’
’
Patient
P P
P P
P P P P a a
a a
a a t t
a a a a
a a a a
t t t t
t t
t t t t
i i
i i i i
e e
e e e e
n n
n n n n
t t
t t
t t
AND AGREED TO BY:
BY Y : :
Parent or guardian if patient is a minor
P P
P P P P P
a a
a a a a
a a a a
a a a a
r r
r r r r
e e
e e
n n
n n
n n t t
t t
t t o o
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f f p p a a ti ti
ti ti a a a a e e
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i i
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s s
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a a
a a a a a a m m
m
i
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i i
i
nor
n
r
parents and adult children
p
p
p p p a
a
a a
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r
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e
e n
n
n
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t
t
s s
s
a a nd nd
a a a a
d d d d nd nd d
a a
a a
a a
a a
du d
Health care agent
H
H H
H H ealt
ealt
ealt
ealth h
t t
t t t t
h h h h h h
h h
h h r r
ca ca
ca ca ca ca
a a a a
a a a a a a e a
r r
r r
e a
e e
g g e e
e e
n n
n n
n n t t
Majority of patient’s reasonably available
M
M M M M M
a
a j
a
a a o
j
j j
j
j
o o o
r
r r
it
it i
t t
y
y
Check The
Legal guardian of the person
Le Le
L L g g
e e
g g
a a
a a
l l
l l
gu gu
g g g u gu u u a a
a a
r r a a a a d d ia ian n a a a a o o
o o
o o f f t t f f h h t t t t e e pe
e
r
r
s s
s
s o o
o o
o o n n
n n
n n
adult siblings
a
a a
du
du d d
ult
lt
Appropriate
Basis for order must be
rd d
r r e e
d d
d d d d
d d d d
e e
r r
r r
m
m m
u
u u
s u u t
t
b
b
b e e
Attorney-in-fact with power to make
A A
A A A A A A
tt tt
tt tt t t
o o
o o
r r
r r
n n n n r r r r
n n
e e
e e
y y
y y
- -
- - i i
i i
n n i i i i -f -fact
f f f f
act
ct ct
t t
w w it ith h t t t t p p
p p
p o po
o o o
w
w w
e
e e
r r t t
t t
o o
m m
m m
a a
a a
a a
a a a a
k k
k k
e e
e e
An individual with an established relationship
Box
documented in medical
en
n n
n n
te te
te te
e e t t
e e
d d
d d i i
d d n n
i i
n n i i i i
m m e e
e
d
d
i d d c
i i a
c
a
a
a
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health care decisions
h h
h h h h
e e
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alth h
h h h h t t t t a a
h h r r
ca ca
c ca a
a a a a
a a
r r
e e d d e e c c i i
i i
s s
s s
s s i i on ons s
with the patient who is acting in good faith and
record.
cord r . d
Spouse
S S
S S
S S p p
p ou
pou
pou
pou
pou
pous s
s s
e e
e e
can reliably convey the wishes of the patient
MD/DO, PA, or NP Name (Print):
P Nam
m m
m m m m m m
e e
e e
e e
e e e e ( ( Pr Print
int
nt
nt) )
) )
: :
: :
MD/DO, PA, or NP Signature (Required):
M M
M M M M M M
D D
D D / /
/ / D D
D D D O O
O O
O O , ,
, , P P
P P
A A
A A
, , o o
o o
o o r
r r
NP
NP S S
S S
S S i i
g g
g g
n
n
Phone #:
Signature of Person, Parent of Minor, Guardian, Health Care Agent, Spouse, or Other Personal Representative
ignature of Pers
Paren
n n
n n
t
t t
t t t t
o o
o o
o o
o f M M
M M
i i
i i
n n
n n n n
o o
o o
r r
r r
, , G G
G u
G
G u
G
G u
Guar r d d
d d
i i
i i
i i a a
a a a a a a
n n
n n n n n n
, , He
Healt
(Signature is required and must either be on this form or on file)
Signatu is re
nd mus
s s
s s
t t
t t
e e
e e
e e
e e e e i i
i i
i th
ith
h h
er er
e e
b b e e on on th th
thi
thi
thi his
s f f o o f f f f r r m m
I agree that adequate information has been provided and significant thought has been given to life-prolonging measures.
agree that adequate
rmation
on on
n n
h h
h h
h h
h h h h
a a
a a
a a
a a
s
s s b b e e e e n n
n n
p p
p p
r r
r r
ovid
ovid
d
d
Treatment preferences have been expressed to the physician (MD/DO), physician assistant, or nurse practitioner. This
eatment preferences h e been e
e e
xp
xp xp
xp
xpre
re
re
re r
s
s s s s e e d d
d d
document reflects those treatment preferences and indicates informed consent.
ument refl f ects those tr tment pre
e f efe f
f
If signed by a patient representative, preferences expressed must reflect patient’s wishes as best understood by that
y a patient rep e re ntati
representative. Contact information for personal representative should be provided on the back of this form
ntative. Contact inf
.
You are not required to sign this form to receive treatment.
not req
uired to
Patient or Representative Name (print)
presentati
Patient or Representative Signature
Relationship (write “self” if patient)
SEND FORM WITH PATIENT/RESIDENT WHEN TRANSFERRED OR DISCHARGED
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