Indiana Physician Orders For Scope Of Treatment (Post)
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2HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AS NECESSARY FOR TREATMENT
Indiana Physician Orders for Scope of Treatment (POST)
Patient First Name
Middle Init.
Patient Last Name
Follow these orders first. Contact treating physician,
advanced practice nurse, or physician assistant for
further orders if indicated. Emergency Medical
Birth date (mm/dd/yyyy)
Date prepared (mm/dd/yyyy)
M
F
Services (EMS) should contact Medical Control per
protocol. These medical orders are based on the
Address (street / city / state / zip)
patient’s current medical condition and preferences.
Any section not completed does not invalidate the
form and implies full treatment for that section.
C
R
(CPR):
Patient has no pulse AND is not breathing
ARDIOPULMONARY
ESUSCITATION
A
Attempt Resuscitation/CPR
Do Not Attempt Resuscitation/DNR
Check
One
When not in cardiopulmonary arrest, follow orders in B and C and D
M
I
:
If patient has pulse AND is breathing OR has pulse and is NOT breathing.
EDICAL
NTERVENTIONS
B
Comfort Measures (Allow Natural Death). Relieve pain and suffering through the use of any medication by
Check
any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway
One
obstruction as needed for comfort. Patient prefers no transfer to hospital for life-sustaining treatments.
Transfer to hospital ONLY if comfort needs cannot be met in current location.
Treatment Goal: Maximize comfort through symptom management.
Limited Additional Interventions In addition to care described in Comfort Measures Only,
use medical
treatment for
stabilization, IV fluids (hydration) and cardiac monitor as indicated to stabilize medical condition.
May use basic airway management techniques and non-invasive positive-airway pressure. Do not intubate.
Transfer to hospital if indicated to manage medical needs or comfort. Avoid intensive care if possible.
Treatment Goal: Stabilization of medical condition.
Full Intervention In addition to care described in Comfort Measures Only and Limited Additional
Interventions, use intubation, advanced airway interventions, and mechanical ventilation as indicated.
Transfer to hospital and/or intensive care unit if indicated to meet medical needs.
Treatment Goal: Full interventions including life support measures in the intensive care unit.
Additional Orders:
A
:
NTIBIOTICS
C
Use antibiotics for infection only if comfort cannot be achieved fully through other means.
Check
Use antibiotics consistent with treatment goals.
One
Additional Orders:
:
D
A
A
N
Always offer food and fluid by mouth if feasible
RTIFICIALLY
DMINISTERED
UTRITION
No artificial nutrition.
Check
One
Defined trial period of artificial nutrition by tube.
(Length of trial: ________ Goal: _______________________)
Long-term artificial nutrition.
Additional Orders:
D
D
:
OCUMENTATION OF
ISCUSSION
E
Patient (patient has capacity)
Legal Guardian/Parent of Minor
Orders discussed
Health Care Representative
Health Care Power of Attorney
with (check one):
S
P
L
A
S
(see back)
IGNATURE OF
ATIENT OR
EGALLY
PPOINTED
URROGATE
Signature (required)
Print Name (required)
Date (required)
S
P
F
IGNATURE OF
HYSICIAN
My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s current medical condition and preferences.
Physician office Phone Number
Print Signing Physician Name (required)
License Number
(
) _____ – _________
Office Use Only
Date (required)
Physician Signature (required)
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