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Kansas Transportable Physician Orders For Patient Preferences (TPOPP) Form

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Kansas Transportable Physician Orders For Patient Preferences (TPOPP) Form Page 2
Kansas Transportable Physician Orders For Patient Preferences (TPOPP) Form
Completing a TPOPP form is always voluntary. TPOPP is a useful tool for the understanding of and implementation
of physicians’ orders that are reflective of the current medical condition and preferences of a patient. The orders are
to be respected by all receiving providers in compliance with institutional policy. On admission to the hospital setting,
a physician who will issue appropriate orders for that inpatient setting will assess the patient.
TPOPP is a physician order set and as such does not replace Advance Directives but should serve to clarify them.
TPOPP must be completed by a health care provider based on patient preferences and medical indications. Upon
completion it must be signed by a physician and patient (or representative) to be recognized as valid.
Use of original form is strongly encouraged. Photocopies and Faxes of signed TPOPP forms are valid.
A copy should be retained in patient’s medical record.
Health Care Providers Assisting with Form Preparation
More Information: [email protected]
A patient with capacity can, at any time, request alternative treatment.
A patient with capacity can, at any time, revoke a TPOPP by any means that indicates intent to revoke. It is recommended
that revocation be documented by drawing a line through Sections A through D, writing “VOID” in large letters, and
signing and dating this line.
TPOPP form should be reviewed when:
The person is transferred from one care setting or care level to another, or
There is a substantial change in the person’s health status, or
The person’s treatment preferences change.
If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest
compressions should be used on a person who has chosen “Do Not Attempt Resuscitation.”
Name:
Title: Phone:
Name:
Title: Phone:
FORM SHALL ACCOMPANY PERSON WHEN TRANSFERRED OR DISCHARGED
ADVANCE DIRECTIVE AND DURABLE POWER OF ATTORNEY FOR HEALTHCARE DECISIONS
Healthcare Directive or other Advance Directive No Yes
No Yes
Durable Power of Attorney for Healthcare Decisions document*
*Name: Phone:
E.
Completing TPOPP
Using TPOPP
Any incomplete section of TPOPP implies full treatment for that section.
SECTION A:
If person desires IV fluids, indicate “Limited Interventions” or “Full Treatment.”
Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP),
bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations.
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., treatment of a hip fracture).
SECTION B:
Reviewing TPOPP
Modifying and Voiding TPOPP
HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AND PROXY DECISION MAKERS AS NECESSARY FOR TREATMENT
© Center For Practical Bioethics, 1111 Main, Suite 500 (Harzfeld Building), Kansas City, MO 64105 | 816-221-1100
September 2012
Last Name:
First Name: Middle Initial:
Date of Birth: Last 4 SSN:
Gender:
M F
- For Educational Purposes Only -
Kansas Transportable Physician Orders For Patient Preferences (TPOPP) Form
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