ATTENTION: IF YOU USE THIS FORM, PLEASE AKNOWLEDGE SUSAN HICKMAN, PhD
POLST QUALITY IMPROVEMENT:
CHART REVIEW
1. Presence of POLST Form:
a. Is a POLST Form present?
q No q Yes (go to question 2)
b. If NO, why not? q new admission q resident refused
q unknown q other ______
IF NO POLST, PROCEED TO NEXT CHART
2. POLST form description:
a. Number: Is there more than one POLST form present?
q No q Yes. If yes, why? ______
BASE REST OF RESPONSES ON MOST RECENT FORM IN CHART
b. Format: q original pink form q photocopy q fax q other______
c. Version: q California q Oregon q other ______
d. Location: q Front of chart q Protective sleeve q MD Orders
q special AD section q other ______
e. Length of time to POLST completion:
Date of admission:______
Date POLST form signed by patient/surrogate: ______
Date POLST form signed by MD: ______
3. Section A--Resuscitation orders:
a. Is a Resuscitation Order marked?
q No q Yes. If yes, what is marked?
q Resuscitate q Do Not Resuscitate
b. Are there any modifications to this section?
q No q Yes. If yes, describe. ______
4. Section B--Medical Interventions:
a. Is a Medical Order marked?
q No q Yes. If yes, what is marked?
q Comfort Measures Only
q Limited Additional Interventions
q Full Treatment
b. Are other instructions provided about Medical Interventions?
q No q Yes. If yes, describe.______
c. Are there any modifications to the Medical Interventions orders?
q No q Yes. If yes, describe.______
6. Section C—Antibiotics:
a. Is an Antibiotics order marked?
q No q Yes. If yes, what is marked?
q No antibiotics
q Determine use or limitation when infection occurs
q Use antibiotics
b. Are other instructions provided about Antibiotics?
q No q Yes. If yes, describe.______
c. Are there any modifications to the Antibiotics orders?
q No q Yes. If yes, describe.______
7. Section D—Artificially Administered Nutrition:
a. Is an Artificial Nutrition order marked?
q No q Yes. If yes, what is marked?
q No artificial nutrition by tube.
q Defined trial period of artificial nutrition
q Long-term artificial nutrition
b. Are other instructions provided about Artificially Administered Nutrition?
q No q Yes. If yes, describe.______
c. Are there any modifications to the Artificially Administered Nutrition orders?
q No q Yes. If yes, describe.______
8. Summary of Medical Condition and Signature:
a. Discussed with:
q Patient/resident q health care representative q court-appointed guardian
q spouse q parent of minor q other______q blank
b. Summary of Medical Condition:
q patient wishes q specific medical diagnosis q physician orders
q vague medical information q blank q other ______
c. Physician/Nurse Practitioner signature: q blank q signed
d. Name of Physician/Nurse Practitioner:______ q Facility medical director
q Community PCP
q Hospital MD/NP
q Unknown
q Other ______
e. Phone number: q blank q present
f. Patient/Surrogate signature: q blank signed
9. Modifications to POLST form:
q None q Yes. If yes, how?
q bar code q organizational logo q words crossed out q patient identifier
q other______
10. POLST form review:
q No q Yes.
If yes, what was the outcome of the most recent review?
q no change q voided/new form completed q voided/no new form
11. Other issues noted: ______
______
______