Medical Orders For Scope Of Treatment (Page 2 of 2) in pdf

HIPAA PERMITS DISCLOSURE OF MOST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY

Contact Information

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Cell Phone #:

Health Care Professional Preparing Form:

Preparer Title:

Preferred Phone #:

Date Prepared:

Directions for Completing Form

Completing MOST

MOST must be reviewed and prepared by a health care professional in consultation with the patient or patient

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representative.

MOST is a medical order and must be reviewed and signed by a licensed physician (MD/DO), physician assistant, or

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nurse practitioner to be valid. Be sure to document the basis for the order in the progress notes of the medical

record. Mode of communication (e.g., in person, by telephone, etc.) also should be documented.

The signature of the patient or their representative is required; however, if the patient’s representative is not reasonably

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available to sign the original form, a copy of the completed form with the signature of the patient’s representative must

be placed in the medical record and “on file” must be written in the appropriate signature field on the front of this form

or in the review section below.

Use of original form is required. Be sure to send the original form with the patient.

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MOST is part of advance care planning, which also may include a living will and health care power of attorney

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(HCPOA). If there is a HCPOA, living will, or other advance directive, a copy should be attached if available. MOST

may suspend any conflicting directions in a patient’s previously executed HCPOA, living will, or other advance

directive.

There is no requirement that a patient have a MOST.

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MOST is recognized under N.C. Gen. Stat. 90-21.17.

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Reviewing MOST

This MOST must be reviewed at least annually or earlier if:

The patient is admitted and/or discharged from a health care facility;

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There is a substantial change in the patient’s health status; or

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The patient’s treatment preferences change.

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If MOST is revised or becomes invalid, draw a line through Sections A – E and write “VOID” in large letters.

Revocation of MOST

This MOST may be revoked by the patient or the patient’s representative.

Review of MOST

Review Date

Reviewer and

MD/DO, PA, or NP

Signature of Patient or

Outcome of Review

Location of Review

Signature (Required)

Representative (Required)

No Change