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Tennessee Physician Orders For Scope of Treatment (POST) Form

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Tennessee Physician Orders For Scope of Treatment (POST) Form Page 2
Tennessee Physician Orders For Scope of Treatment (POST) Form
HIPAA PERMITS DISCLOSURE OF POST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Signature of Patient, Parent of Minor, or Guardian/Health Care Representative
Significant thought has been given to life-sustaining treatment. Preferences have been expressed to a physician
and/or health care professional(s). This document reflects those treatment preferences.
(If signed by surrogate, preferences expressed must reflect patient’s wishes as best understood by surrogate.)
Signature Name (print) Relationship (write “self” if patient)
Contact Information
Surrogate Relationship Phone Number
Health Care Professional Preparing Form Preparer Title Phone Number Date Prepared
Directions for Health Care Professionals
Completing POST
Must be completed by a health care professional based on patient preferences, patient best interest, and medical
indications.
POST must be signed by a physician to be valid. Verbal orders are acceptable with follow-up signature by
physician in accordance with facility/community policy.
Photocopies/faxes of signed POST forms are legal and valid.
Using POST
Any incomplete section of POST implies full treatment for that section.
No defibrillator (including AEDs) should be used on a person who has chosen “Do Not Attempt Resuscitation”.
Oral fluids and nutrition must always be offered if medically feasible.
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).
IV medication to enhance comfort may be appropriate for a person who has chosen “Comfort Measures Only”.
Treatment of dehydration is a measure which prolongs life. A person who desires IV fluids should indicate
“Limited Interventions” or “Full Treatment”.
A person with capacity, or the surrogate of a person without capacity, can request alternative treatment.
Reviewing POST
This POST should be reviewed if:
(1) The patient is transferred from one care setting or care level to another, or
(2) There is a substantial change in the patient’s health status, or
(3) The patient’s treatment preferences change.
Draw line through sections A through E and write “VOID” in large letters if POST is replaced or becomes
invalid.
Approved by Tennessee Department of Health, Board for Licensing Health Care Facilities, February 3, 2005
COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED.
DO NOT ALTER THIS FORM !
Tennessee Physician Orders For Scope of Treatment (POST) Form
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