Indiana Physician Orders For Scope Of Treatment (Post) (Page 2 of 2) in pdf

The POST form is always voluntary. POST is based on your goals of care and records your wishes for medical treatment. Once initial

medical treatment is begun and the risks and benefits of further therapy are clear, your treatment wishes may change. Your medical care

and this form can be changed to reflect your new wishes at any time. However, no form can address all the medical treatment decisions

that may need to be made. An Advance Directive, including appointing someone to speak on your behalf if you cannot speak for yourself,

is recommended. You can identify a health care representative in the box below if you have not already done so.

Designation of Health Care Representative (Optional)

I hereby appoint: Name: _________________________________ phone #: (

) ________________________

Relationship to patient: _______________ Address: ______________________________________________________

as my representative to act in my behalf on all matters concerning my health care, including but not limited to providing

consent or refusing to provide consent to medical care, surgery, and/or placement in health care facilities, including

extended care facilities. This appointment shall become effective at such time and from time to time as my attending

physician determines that I am incapable of consenting to my health care.

Patient Signature:

Date:

Witness (adult other than legally appointed surrogate):

Contact Information

Surrogate identified in section E (required if patient has no

Address

Phone Number

capacity)

Healthcare Professional Preparing Form

Preparer Title

Phone Number

Directions for Health Care Professionals

Completing POST

•

POST orders should reflect current treatment preferences of the patient.

•

If the patient lacks decisional capacity, form may be completed by legally appointed guardian, healthcare representative,

healthcare power of attorney, or parent of minor.

The authority of the named surrogate is bound by Indiana statutes.

•

Verbal / phone orders are acceptable with follow-up signature by physician in accordance with facility/community policy.

•

The POST form is the personal property of the patient. Use of original form is encouraged, however photocopies and

faxes are also legal and valid

Using POST

• Any section of these Medical Orders not completed implies full treatment for that section.

• Oral fluids and oral nutrition must always be offered if medically feasible.

• Comfort care is never optional. When comfort cannot be achieved in the current setting, the person, including someone

with “Comfort Measures Only,” should be transferred to a setting able to provide comfort (e.g., hip fracture).

• Persons who are in need of emergency medical services due to a sudden accident or injury outside the scope of the

person’s illness should receive treatment to manage their medical needs.

• IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only.”

• Treatment of dehydration is a measure that may prolong life. A person who desires IV fluids should indicate “Limited

Interventions” or “Full Treatment” in section B on page one of this form.

• If a health care provider considers these orders medically inappropriate, he or she may discuss concerns and revise

orders with the consent of the patient or authorized surrogate.

• If a health care provider or facility cannot comply with the orders due to policy or personal ethics, the provider or facility

must arrange for transfer of the patient to another provider or facility and provide appropriate care in the meantime.

•

In the event the patient is hospitalized, the admitting physician should evaluate the patient and review the POST form.

New orders may be recommended based on the patient’s condition and their known preferences or, if unknown, the

patient’s best interest.

Reviewing POST

This form should be periodically reviewed and in the following circumstances:

• There is a substantial change in the patient’s health status.

•

The patient is transferred from one care setting or care level to another or the treating physician changes.

•

The patient’s treatment preferences change.

Voiding POST

•

A person with capacity, or the valid surrogate of a person without capacity, can void the POST orders and any time.

•

Draw line through sections A through D and write “VOID” in large letters if POST is replaced or becomes invalid.

•

If included in an electronic medical record, follow voiding procedures of facility/community.

Indiana Physician Orders For Scope Of Treatment (Post) Page 2

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