Indiana Physician Orders For Scope of Treatment (POST) Form
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INDIANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (POST)
State Form 55317 (6-13)
Indiana State Department of Health – IC 16-36-6
INSTRUCTIONS: Follow these orders first. Contacttreating physician, advanced practice nurse, or physician assistant for further orders if indicated.
Emergency Medical Services (EMS) should contact Medical Control per protocol. These medical orders are based on the patient’s current medical
condition and preferences. Any section not completed does not invalidate the form and implies full treatment for that section.HIPAA permits disclosure
to health care professionals as necessary for treatment.Original form is personal property of the patient.
Patient Last Name
Patient First Name
Birth date (mm/dd/yyyy)
Medical Record Number
Date prepared (mm/dd/yyyy)
CARDIOPULMONARY RESUSCITATION (CPR):Patient has no pulse AND is not breathing.
AttemptResuscitation/CPRDo Not Attempt Resuscitation (DNR)
When not in cardiopulmonary arrest, follow orders in B,Cand D.
MEDICAL INTERVENTIONS:If patient has pulse AND is breathing OR has pulse and is NOT breathing.
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