North Carolina Medical Orders For Scope of Treatment (MOST) Form
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HIPAA PERMITS DISCLOSURE OFMOST TOOTHER HEALTHCARE PROFESSIONALS AS NECESSARY
Patient’s LastName: Effective Dateof Form:
___________________
Form mustbe reviewed
atleast annually.
Medical Orders
for Scope of Treatment (MOST)
This is a Physician Order Sheet based on the person’s medical
condition and wishes. Any section not completed indicates full
treatment for that section.
When the need occurs, first
follow
these orders, then
contact physician.
Patient’s First Name, Middle Initial: Patient’s Dateof Birth:
.
Section
C
Check One
Box Only
ANTIBIOTICS
Antibiotics if life can be prolonged.
Determine use or limitation of antibiotics when infection occurs.
No Antibiotics (use other measures torelieve symptoms).
Section
D
Check One
Box Only in
Each
Column
MEDICALLY ADMINISTERED FLUIDS AND NUTRITION: Offer oral fluids and nutrition if
physically feasible.
IV fluids long-term if indicated Feeding tube long-term if indicated
IV fluids for a defined trial period Feeding tubefor a defined trial period
No IV fluids (provideother measures to ensure comfort)No feeding tube
Section E
Check The
Appropriate
Box
DISCUSSED WITH
Patient
Majorityof patient’s reasonably available
AND AGREED TO BY:
Parentor guardian ifpatient is a minor parents and adult children
Health care agent Majorityof patient’s reasonably available
Legal guardianof the person adult siblings
Basis for order must be
Attorney-in-fact withpower to makeAn individual with an established relationship
documented inmedical health care decisions with the patient who is acting ingoodfaith and
record.
Spouse can reliably convey the wishes of the patient
MD/DO, PA, or NP Name(Print): MD/DO, PA, or NP Signature (Required): Phone #:
Signature ofPerson, Parent ofMinor, Guardian, Health CareAgent,Spouse, or Other Personal Representative
(Signature is required and must either beon this form oron file)
I agree that adequateinformation has been provided and significant thought has been given to life-prolonging measures.
Treatment preferences have been expressed tothe physician (MD/DO), physician assistant,ornurse practitioner. This
document reflects those treatment preferences and indicates informed consent.
If signed bya patient representative, preferences expressed must reflect patient’s wishes asbest understood bythat
representative.Contact information for personal representative should beprovided on the back of this form
.
You are not required to sign this form to receive treatment.
Patient or Representative Name(print) Patient or Representative SignatureRelationship (write“self”ifpatient)
SEND FORM WITH PATIENT/RESIDENTWHEN TRANSFERRED OR DISCHARGED
Section
A
Check One
Box Only
Section
B
Check One
Box Only
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Other Instructions
Other Instructions
Other Instructions
.
CARDIOPULMONARY RESUSCITATION (CPR):Person has no pulse and is not breathing.
Attempt R
esuscitation (CPR) Do NotAttempt Resuscitation (DNR/no CPR)
Whennot incardiopulmonary arrest, follow ordersinB, C, and D.
MEDICALINTERVENTIONS: Person has pulse and/or is breathing.
Full Scope of Treatment:
Use intubation, advanced airway interventions, mechanical ventilation, cardioversion as
indicated, medical treatment, IV fluids, etc.; alsoprovide comfort measures. Transfer to hospital if indicated
.
Limited Additional Interventions: Use medical treatment,IV fluids and cardiac monitoring as indicated.
Do notuse intubation or mechanical ventilation; also provide comfort measures. Transfer to hospital if indicated
.
Avoid intensive care.
Comfort Measures:Keep clean,warm and dry.Use medication by any route, positioning, wound care and
other measures torelieve pain and suffering.Use oxygen, suction and manual treatmentof airwayobstruction as needed
for comfort. Do nottransfer to hospital
unless comfort needs cannot be met incurrent location.