New Hampshire Polst Form Page 2
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2HIPAA PERMITS DISCLOSURE TO HEALTH PROFESSIONALS INVOLVED IN THE PATIENT’S CARE
Information for Patient Named on this form – Patient’s Name (print):__________________________________________
This voluntary form records your preferences for life-sustaining treatment in your current state of health. It can be
reviewed and updated by you and your health care professional at any time if your preferences change. If you are unable
to make your own health care decisions, the orders should reflect your preferences as best understood by your DPOAH,
Guardian or by your written Advance Care Plan.
Contact Information for DPOAH, Guardian or Parent of Minor
(Optional)
Name:
Relationship:
Phone Number:
Address:
(Optional)
Health Care Professional Preparing Form
Name:
Preparer Title:
Phone Number:
Date Prepared:
Directions for Health Care Professionals
Completing POLST
•
Encourage completion of an Advance Directive.
•
Should reflect current preferences of patient with serious illness or frailty whose death within the next year would not
surprise you.
•
Verbal/phone orders are acceptable with follow-up signature by physician/APRN in accordance with facility policy.
•
Use original form if patient is transferred/discharged.
Reviewing POLST
This POLST should be reviewed periodically and if:
•
The patient is transferred from one care setting or care level to another, or
•
There is a substantial change in the patient’s health status, or
•
The patient’s treatment preferences change.
Voiding POLST
•
A patient with capacity, or the activated DPOAH or Court appointed Guardian of a patient without capacity, can void the
form and request alternative treatment.
•
Draw line through sections A through E and write “VOID” in large letters if POLST is replaced or becomes invalid.
•
If included in an electronic medical record, follow voiding procedures of facility.
Review of this POLST Form
Review Date
Reviewer
Location of Review
Signature
:
Review Outcome
No Change
Form Voided
New form completed
Review Date
Reviewer
Location of Review
Signature
:
Review Outcome
No Change
Form Voided
New form completed
Review Date
Reviewer
Location of Review
Signature
Review Outcome:
No Change
Form Voided
New form completed
ORIGINAL TO ACCOMPANY PATIENT IF TRANSFERRED / DISCHARGED
FOUNDATION FOR
HEALTHY COMMUNITIES
125 Airport Rd., Concord, NH 03301-7300
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