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Colorado Medical Orders For Scope of Treatment (MOST) Form

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Colorado Medical Orders For Scope of Treatment (MOST) Form
Colorado Medical Orders For Scope of Treatment (MOST) Form
SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
Last Name
First Name/Middle Name
Date of Birth
Sex
Colorado Medical Orders
for Scope of Treatment (MOST)
FIRST follow these orders, THEN contact Physician, Advanced Practice
Nurse (APN), or Physician Assistant (PA), for further orders if indicated.
These Medical Orders are based on the person’s medical condition & wishes.
Any section not completed implies full treatment for that section.
May only be completed by, or on behalf of, a person 18 years of age or older.
Everyone shall be treated with dignity and respect.
Hair Color Eye Color
Race/Ethnicity
A
Check
One Box
Only
C
ARDIOPULMONARY RESUSCITATION
(CPR)
Person has no pulse and is not breathing.
No CPR Do Not Resuscitate/DNR/Allow Natural Death
Yes CPR Attempt Resuscitation/ CPR
When not in Cardiopulmonary arrest, follow orders B, C, and D
B
Check
One Box
Only
M
EDICAL
I
NTERVENTIONS
Person has pulse and/or is breathing.
Comfort Measures Only: Use medication by any route, positioning, and other measures to relieve pain
and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort.
Do not transfer to hospital for life-sustaining treatment.
Transfer only if comfort needs cannot be met in current location; EMS-Contact medical control.
Limited Additional Interventions: Includes care described above. Use medical treatment, IV fluids
and cardiac monitor as indicated. Do not use intubation, advanced airway interventions, or mechanical
ventilation. Transfer to hospital if indicated. Avoid intensive care; EMS-Contact medical control.
Full Treatment: Includes care described above. Use intubation, advanced airway interventions,
mechanical ventilation, and cardioversion as indicated.
Transfer to hospital if indicated. Includes intensive care. EMS-Contact medical control.
Additional Orders: _______________________________________ (EMS=Emergency Medical Services)
C
Check
One Box
Only
A
NTIBIOTICS
No antibiotics. Use other measures to relieve symptoms.
Use antibiotics when comfort is the goal.
Use antibiotics.
Additional Orders: _______________________________________
D
Check
One Box
Only
A
RTIFICIALLY
A
DMINISTERED
N
UTRITION AND
H
YDRATION
****Always offer food & water by mouth if feasible*****
No artificial nutrition/hydration by tube. (NOTE: Special rules for proxy by statute on page 2)
Patient has executed a “Living Will”
Patient has not executed a “Living Will”
Defined trial period of artificial nutrition/hydration by tube.
(Length of trial: ___________________ Goal:________________________________________)
Long-term artificial nutrition/hydration by tube.
Additional Orders: _______________________________________
D
ISCUSSED WITH
:
Patient
Agent under Medical Durable Power of Attorney
Proxy (per statute C.R.S. 15-18.5-103(6))
Guardian
Other:______________________________________
E
Check
All That
Apply
(SECTION RESERVED FOR FUTURE USE)
S
UMMARY OF
M
EDICAL
C
ONDITION
(
S
):
Physician/APN /PA Signature (mandatory)
Colorado License #:
Print Physician/APN/PA Name, Address and Phone Number
Date
HIPAA PERMITS DISCLOSURE OF THIS INFORMATION TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Colorado Advance Directives Consortium, www.ColoradoAdvanceDirectives.com ; PO Box 270202, Littleton, CO 80127 v.7.10
Colorado Medical Orders For Scope of Treatment (MOST) Form
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