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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
Tennessee Physician Orders For Scope of Treatment (POST) Form
COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED
Patient’s Last Name
First Name/Middle Initial
Physician Orders
for Scope of Treatment (POST)
This is a Physician Order Sheet based on the medical conditions
and wishes of the person identified at right (“patient”). Any section
not completed indicates full treatment for that section. When need
occurs, first
follow these orders, then contact physician.
Date of Birth
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and/or is not breathing.
Resuscitate (CPR)
Do Not Attempt Resuscitate (DNR/no CPR)
Section
A
Check One
Box Only
When not in cardiopulmonary arrest, follow orders in B, C, and D.
Section B
Check One
Box Only
MEDICAL INTERVENTIONS. Patient has pulse and/or is breathing.
Comfort Measures Treat with dignity and respect. Keep clean, warm, and dry.
Use medication by any route, positioning, wound care 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.
Limited Additional Interventions Includes care described above. Use medical treatment, IV fluids and cardiac
monitoring as indicated. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer
to hospital if indicated. Avoid intensive care.
Full Treatment. Includes care above. Use intubation, advanced airway interventions mechanical ventilation, and
cardioversion as indicated. Transfer to hospital if indicated. Include intensive care.
Other Instructions:
Section
C
Check One
Box Only
ANTIBIOTICS – Treatment for new medical conditions:
No Antibiotics
Antibiotics
Other Instructions:
Section
D
Check One
Box Only in
Each
Column
MEDICALLY ADMINISTERED FLUIDS AND NUTRITION. Oral fluids and nutrition must be offered if medically
feasible.
No IV fluids (provide other measures to assure comfort) No feeding tube
IV fluids for a defined trial period Feeding tube for a defined trial period
IV fluids long-term if indicated Feeding tube long-term
Other Instructions:
Discussed with:
Patient/Resident
Health care agent
Court-appointed guardian
Health care surrogate
Parent of minor
Other:
(Specify)
The Basis for These Orders Is: (Must be completed)
Patient’s preferences
Patient’s best interest (patient lacks capacity or preferences unknown)
Medical indications
(Other)
Physician Name (Print)
Physician Phone Number
Section
E
Must be
Completed
Physician Signature (Mandatory)
Date
Office Use Only
COPY OF FORM SHALL ACCOMPANY PATIENT WHEN TRANSFERRED OR DISCHARGED
Tennessee Physician Orders For Scope of Treatment (POST) Form
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