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5 NAME: Reason for admission: During your stay, your doctor and the staff will work with you to plan for your discharge. You and your caregiver (a family member or friend who may be helping you) are important members of the planning team. Below is a checklist of important things you and your care giver should know to prepare for Discharge. Instructions Use this checklist early and often during your stay. Talk to your doctor and staff about the items on the checklist. Use the notes column to write down important information (like names and phone numbers) Skip any items that do not apply Action Items What s Ahead? Ask where you will get care after discharge. Do you have options (like home health care)? Be sure you tell the staff what you prefer. If a caregiver will be helping you after discharge, write down their name and phone number. Your Health Ask the staff about your health condition and what you can do to help yourself get better. Ask about problems to watch for and what to do about them. Write down a name and phone number to call if you have problems. Use My Drug List on page 5 to write down your prescription drugs, over the counter drugs, vitamins, and herbal supplements. Review the list with the staff Tell the staff what drugs, vitamins, or supplements you took before you were admitted. Ask if you should still take these after you leave. Write down a name and phone number to call if you have any questions. Recovery and Support Ask if you will need medical equipment (like a walker). Who will arrange this? Write down where to call if you have any questions about equipment. Ask if you re ready to do the activities listed below. Circle the ones you need help with and tell the staff. Bathing, dressing, using the bathroom, climbing stairs Cooking, food shopping, house cleaning, paying bills Getting to doctors appointments, picking up prescription drugs. Make sure you have support (like caregiver) in place that can help you. See Resources flyer Ask the staff to show you and your caregiver any other tasks that require special skills (like changing bandage or giving a shot). Write down name and phone number to call if you need help. Ask to speak to a case manager if you re concerned about how you and your family are coping with your illness. Write down information about support groups and other resources. Talk to a case manager or your health plan if you have questions about what your insurance will cover and how much you will have t pay. Ask about possible ways to get help with your costs. Ask for written discharge instructions (that you can read and understand) and summary of your current health status. Bring this information and your completed My Drug List to Notes

6 your follow up appointments. Use My Appointments to write down any appointments and tests you will need in the next several weeks. For the Care Giver Do you have any questions about the items on this checklist or on the discharge instructions? Write them down and discuss them with the staff. Can you give the patient the help he or she needs? What tasks do you need help with? Do you need any education or training? Talk to the staff about getting the help you need before discharge. Write down a name and phone number to call if you have any questions. Get prescriptions and any special diet instructions early, so you won t have to make extra trips after discharge. More information for people with Medicare If you need help in choosing a home health agency or nursing home: Visit to compare the quality of home health agencies, nursing homes, dialysis facilities, and hospitals in your area. Call MEDICARE ( ). TTY user should call Local Resources Blythe Police Department: (760) Elderly Abuse Adult Protective Services (APS) (800) Meals o Senior Nutrition Program: Cindy Ruiz (760) o Harmony Kitchen: 219 South Main St. (760) o Blythe Emergency Food Pantry: 181 S Main (760) Home Health Agencies o APISMELLIS Home Care: Berto (928) o 81 Home Health: Elsa Irlanda (714) o Desert Home Health: (760) Hospice Care o Serenity Hospice: Juan (760) o Hospice of Havasu: (888) HospiceHavasu.org Physical Therapy o Hurst Physical Therapy: (760) Child Abuse o Child Protective Services (CPS) (800) Nursing Homes o Blythe Nursing Care Center (BNCC) Kat (760) Medical Equipment o Bandys: (760) (no Medicare contract) o Blythe Drug: Brad (760) o Petersons in Parker: (928) o LinCare: (928) Pharmacy s o Bandy s (760) 922/5165 o Blythe Drug (760) o Rite Aid (760) Dial a ride/taxi o Desert Road Runner (760) o Reliable Ride Taxi (760) Riverside County Department of Mental Health (760) Other Community Resources Riverside County Department of Public Social Service (DPSS) ((Cal Works, food stamps, Medi Cal, General Relief (760) Office of Aging (800) In Home Supportive Services (888) Riverside County Animal Control (760) Veterans Services (800) VA Clinic 1273 W Hobsonway, (760) Blythe Cancer Society (760) Woman, Infant & Children (WIC) (800) Riverside County Community Action (760) Medi Cal Representative/Financial Counselor/Business Office Margarita Rubalcaba (760) Margarita.Rubalcaba@paloverdehospital.org

7 PALO VERDE HOSPITAL MANUAL SECTION: Clinical Hospital Wide Effective Date: Number: Revised Date: 04/16/2013 Review Date: 04/16/2013 Author: Silvia Herrera TITLE: Discharge Planning Section I: Policy Statement To provide guidelines for appropriate discharge planning and patients discharge, and ensure nursing and case management properly prepare inpatients for discharge or referrals for post-hospital Support/Service. Definition: Discharge Planning is the coordinated process that evaluates a patient s needs and ensures that each patient has an individualized plan for continuing care, follow-up and/or rehabilitation. It can also be defined as planning for the appropriate continuing care of the patient upon discharge from an acute care facility. Section II: Scope of Application 1. Nursing staff and case manager are responsible for preparing inpatients for discharge, referrals for posthospital support service and identify prior to or on admission a high risk patients with medical, surgical, or psychosocial problems which have potential for increased lengths of stay or possible readmission. 2. Case Manager or Registered nurse is responsible for the discharge planning to be completed on each inpatient within 24 hours of admission. 3. Health Care Professionals shall evaluate, integrate, and coordinate the discharge planning according to patients needs. 4. Discharge planning shall include the patient, family, significant others, medical staff, nursing staff, case management staff, dietitians, rehabilitation therapists and others as needed to ensure patient has an individualized plan for discharge, continuing care, or follow-up and/or rehabilitation. Section III: Procedural Steps For Implementation All patients will be assessed prior to admission in the ER or at the time of admission to determine their discharge needs. Discharge planning shall be considered for all patients admitted to Palo Verde Hospital. Every hospitalized patient in Palo Verde hospital shall have a written discharge plan that will be given to the patient at the time of discharge PROCESS / OBJECTIVES FOR DISCHARGE PLANNING: 1. Discharge planning begins prior to admission by assessing the following areas: a. The patient s living arrangements prior to hospitalization and the expected living arrangements post-discharge. b. Any significant others who would be available to provide assistance at home. c. The assessment of patient/family psychosocial status. d. Family, support group status. e. The patient s socio-economic status. f. Available community resources and the estimated cost and benefits. g. The patient s ability to perform activities of daily living.

8 PALO VERDE HOSPITAL Title: Discharge Planning Policy Number: Page 2 of 5 h. Special nursing procedures, medication administration, and other special ancillary care services required. 2. The RN in conjunction with the case manager will continuously evaluate the patient for post-hospital needs. The evaluation will determine not only whether the patient will need services but also the type and frequency of those services. Therefore, the nurse should assess the patient, family, and significant other on admission and throughout the hospitalization for: a. Knowledge of disease, wellness, procedures or treatment needed to maintain optimum, independent functioning. b. Emotional, intellectual, sensory and physical ability to learn and carry out treatments and procedures needed for optimum independent functioning. c. Cultural, language, or spiritual considerations that affect teaching and learning. d. Expectation of ability to comply with and adhere to the treatment plan. e. Type and frequency of services, supplies and equipment needed for care in the hospital and after hospitalization. f. Patient s independence in performing ADLs. g. Availability of resources, including but not limited to caregivers, type and location of residence, financial status, and appropriate community services. 3. Ongoing Clinical Assessment / Continuity of Care a. Throughout the patient s hospitalization discharge planning will include ancillary services as needed, and case management for the assessment of the following issues: i. The patient/family psychosocial and emotional status. ii. Any change in the patient s physical status that may affect post-discharge well being (i.e., physical progress or deterioration, new diagnosis, disease or procedure.) iii. Once the alternate care setting has been selected and transfer has taken place, a request is made to the agency or provider for a written progress report when necessary. iv. Identification of Alternate Medical Services: Assess for need for post-hospitalization assistance or services. Collaborate with the case manager and other members of the interdisciplinary team in determining the need for services after discharge. Home health care, hospice, or skilled nursing facility is for patients who may require intermittent professional nursing care outside of Palo Verde Hospital. v. Interdisciplinary/discharge meetings may be utilized to facilitate the collaborative planning process. b. Determination of the need for discharge planning is also determined through use of goal- based criteria. c. The need of all patients for discharge planning should be identified and should commence at the time of admission. d. Case manager must notify for preauthorization to QIO review prior to patient discharge, for precertification of the service provided as part of a patient s discharge plan.

9 PALO VERDE HOSPITAL Title: Discharge Planning Policy Number: Page 3 of 5 e. Health care staff should coordinate post discharge needs and alternative care and to ensure continuity of care throughout inpatient care and following discharge. f. Case Manager should ensure appropriate utilization of inpatient facilities and services. g. Case Manager should prevent iatrogenic complications that may require hospital readmission and to reduce length of stay by preventing unnecessary inpatient days. h. Case Managers and nursing staff should instruct patients, families and significant others in needed aspects of patient care. Provide printed and/or electronic materials, as appropriate. PROCEDURE 1. The RN is responsible for identifying the learning needs of patients, families, and significant others and for implementing the teaching plan. 2. Palo Verde Hospital staff has direct effect in patient care and shall enhance continuity of care through the appropriate utilization of hospital services, institutional facilities and appropriate community resources. 3. Clinical Case Managers are responsible for assisting patients and families with coordination of all home care services and assists patients and families in completing and processing applications for extended care facilities and hospice placement. The Case Manger Department evaluates financial and psychological needs. 4. Physicians are responsible for completing discharge summaries and the sections related to treatments and medications. The physician writing the discharge order utilizing EMR Order Entry for electronic discharges should write the order for physician consultation or follows up. 5. Medication reconciliation form is completed prior to discharge. 6. At the time of discharge, all inpatients shall be escorted by a member of the transportation department, volunteer services, or by a staff member from the discharging unit. Patients with complicated discharge needs and/or circumstances that may delay discharge should be reported to the case manager and the nursing manager. 7. The hospital maintains transfer agreements for inpatient-to inpatient referrals. These are triaged through the Case Management Department. 8. Patient advocate will make post discharge follow up telephone calls to ensure best patient outcomes and proactively reduce the readmissions. DESIRED PATIENT OUTCOMES: 1. At the time of discharge, the patient, family, and/or significant other will verbalize understanding of the following: diet, medications, activities/treatment, follow-up appointments and any community referral for services or equipment. 2. The patient will achieve an optimal level of functioning after discharge from Palo Verde Hospital.

10 PALO VERDE HOSPITAL Title: Discharge Planning Policy Number: Page 4 of 5 DOCUMENTATION: 1. Progress notes addressing discharge planning will be written within 24 hours of admission, at least every 72 hours, and with any change in discharge status or plan. Daily notes may be required for complicated cases or short-term hospitalizations. a. If there are no discharge issues identified at the time of initial assessment, patient goals and a preliminary discharge plan should be established and documented in the progress notes. b. The discharge goals and plan are reviewed and updated periodically as the patient s condition warrants. c. The patient and/or family sign the EMR clinical discharge instructions and teaching regarding discharge planning. d. If the patient is discharged to a long term facility or home care services and the patient and/or family should sign the discharge consent indicating their awareness of the patient s destination/agency choice. e. If the patient is unable to sign and there is not family available, the discharge nurse may indicate that the patient/family is unable or unavailable to sign. APPROVED SPECIAL STANDARDS FOR THE FOLLOWING SITUATIONS ARE: 1. OB/GYN: a. For antenatal women admitted for long term hospitalization, Discharge Planning will be addressed at least every 4 days. 2. PERINATAL: a. The following Patient Care Problems will be addressed as indicated per unit specific documentation procedure. b. Availability of resources, including but not limited to caregivers, type and location of residence, financial status, and community services. c. Assess for need for post-hospitalization assistance or services collaborate with the case manager and other members of the interdisciplinary team in determining the need for services after discharge. d. The interdisciplinary team will evaluate the necessity of frequent discharge Planning Evaluation or lack there off. 3. MED SURG OR TELEMETRY DEPARTMENT UNIT: Discharge Planning: Discharge planning documentation will be completed on admission and updated every 3 days and at discharge. 4. Updated patient care should reflect the patient s status at the time of discharge. Unresolved problems require a progress note. Case manager or Nursing staff should document any referrals that have been made.

11 PALO VERDE HOSPITAL Title: Discharge Planning Policy Number: Page 5 of 5 a. If at the time of initial assessment it is determined that the patient cannot return home or will be unable to care for himself/herself independently in the home setting, the nursing staff in conjunction with the departments of case management will assist in planning for continuity of care. b. Patients who seem to be unable to return home or who were admitted from another facility are referred to the case management department. 5. Document patient teaching on the Patient and Family Teaching Record. Include understanding of follow-up plans, resources and ongoing educational needs. 6. On the day of discharge, complete discharge Instructions, physician follow up and Medication Reconciliation Form for all patients. The discharging nurse must sign and complete and/or review the diet, activities, dressings, treatments, services and medications sections, including medication reconciliation. a. Patient discharge without services: i. Physician discharge Note or summary. ii. Prescriptions. iii. Discharge instructions. Shall Include activity, diet and follow up with primary care physician. iv. Discharge checklist and resource guide b. Patient discharge with services: i. Fax or send EMR discharge Instructions to appropriate homecare provider. ii. Advance Directive or Living will if applicable iii. Physician discharge note or summary. iv. Physical Therapy Summary, if appropriate Patients who seem to be unable to return home or who were admitted from another facility are referred to the case management department. v. Document patient teaching on the Patient and Family Teaching Record. Include understanding of follow-up plans, resources and ongoing educational needs. vi. The inmate patient population will be transferred according to the proper correctional Facility guidelines. vii. Discharge checklist and resource guide Section IV: References California Health and Safety Code: Division 2 Licensing Provisions: Chapter 2 Health Facilities Article 1 General (Written discharge policy and process; Transfer summary). Center for Medicare advocacy, Inc: Discharge Planning across Care Setting: The Acute Care Hospital Setting. Department of Health and Human Services: Discharge Planning. Condition of participation for Hospitals: Part 482. Discharge Planning. Palo Verde Hospital Discharge Checklist April 2013 Palo Verde Hospital Medicare Resource guide April 2013

12 Resources The agencies listed here have information on community services, (like home delivered meals and rides to appointments). You can also get help making long term care decisions. Ask the staff in your healthcare setting for more information. Area Agencies on Aging (AAAs) and Aging and Disability Resources Centers (ADRCs): Help older adults, people with disabilities, and their caregivers. To find the AAA/ADRC in your area, visit the Eldercare Locator at or call weekdays from 9a.m. 8 p.m. Ask Medicare: Provides information and support to caregivers of people with Medicare. Visit Long Term Care (LTC) Ombudsman Program: Advocate for and promote the rights of residents in LTC facilities. Senior Medicare Patrol (SMP) Programs: Work with seniors to protect themselves from the economic and health related consequences of Medicare and Medicaid fraud, error, and abuse. To find a Local SMP program, visit Centers for Independent Living (CILs): Help people with disabilities live independently. For a state bystate directory of CILs, visit State Technology Assistance Projects: Has information on medical equipment and other assistive technology. Visit or call to get the contact information in your state. National Long Term Care Clearinghouse: Provides information and resources to plan for your longterm care needs. Visit National Council on Aging: provides information about programs that help pay for prescription drugs, utility bills, meals, health care, and more. Visit State Health Insurance Assistance Programs (SHIPs): offer counseling on health insurance and programs for people with limited income. Also help with claims, billing, and appeals. Visit or call MEDICARE ( ) to get your SHIP s phone number. TTY users should call State Medical Assistance (Medicaid) Office: Provides information about Medicaid. To find your local office, visit or call MEDICARE and say, Medicaid. The information in this booklet was correct when it was printed. Changes may occur after printing. Visit or call MEDICARE to get the most current information. Your Discharge Planning Checklist isn t a legal document. Official Medicare Program Legal guidance is contained in the relevant statutes, regulations, and rulings.

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63 PALO VERDE HOSPITAL MANUAL: CLS Clinical Hospital Wide Effective 08/08 Number: 16.0 Date: Reviewed: 06/10 Revised: 06/10 BOARD James Carney CHAIRMAN CEO: Peter Klune DIRECTOR: AUTHOR TITLE: Advance Directives Page 1 of 3 Section I: Purpose To provide anatmosphere of respect and caring and to ensure that each patient s ability and right to participate in medical decision making is maximized and not compromised as a result of admission for care through Palo Verde Hospital. Additionally, the purpose of this policy is to assure compliance with the Patient Self- Determination Act (PSDA) in such a manner as to expand the patient, personal and community knowledge base regarding advance directives and the process by which patient participation in medical decision making is carried out at this facility. Section II: Who may Perform/Responsible The registered nurse (R.N.) and other licensed healthcare providers who are practicing within their scopes. Section III: Policy This is the policy of Palo Verde Hospital to respect and encourage patient selfdetermination. Patients will be encouraged and assisted to be active participants in the decision making process regarding their care through education, inquiry and assistance as requested. Patients will be encouraged to communicate their desires in regard to advanced directives to their significant others, to allow for guidance of significant others and healthcare provides in following the patient s wishes should the patient become incapacitated, rendering them unable to make decisions. The existence of an advance directive, or lack thereof, will not determine the patient s access to care, treatment and services. Section VI: Procedure An inquiry will be made by the Admitting Department during the admission process of the patient, or if the patient is incapacitated, to the patient s significant other, as to whether or not the patients has completed advance directives. Palo Verde Hospital shall not condition the provision of care or otherwise discriminate against any individual based on whether or not the individual has executed an advanced directive. A request of the patient/significant other to provide a copy of the advance directive for medical record entry will be made by the Admitting Department during the admission

64 PALO VERDE HOSPITAL Title: Advance Directives Policy Number: 16.0 Page 2 of 3 process. As part of the admission process the patient/significant other will be provided with an information packet outlining the individual s right to make decisions concerning medical care. The information packet provided will include: o The right to accept or refuse medical or surgical treatment, even if the treatment is life sustaining; o Information concerning the Patient Self- Determination Act; o Palo Verde Hospital s mission and value statements and policies regarding refusal of medical treatment, including life-sustaining measures; o That the existence of an advanced directive, or lack thereof, will not determine the patient s right to care, treatment or services; o Definitions of pertinent healthcare terminology as they apply to the Patient Self Determination Act. o Policy regarding the patient s right to voice a complaint related to advance directive requirements to the State Department of Health Services; o Contact personnel available to assist those interested in pursuing the advance directive issue; o Information regarding the PSDA will be provided to the patient upon each admission to Palo Verde Hospital. Admitting Department personnel will document in the medical record whether the patient has completed an advanced directive and that information concerning advanced directives has been given to the patient/significant other during the admission process. In the event that the patient bypasses the routine admission process due to nature or severity of illness, and is admitted directly to the patient care units, the responsibility to inquire about advance directives and provide necessary information as outlined above will rest with the nursing staff. The Admitting Department will notify the nursing staff of the need for advance directive follow-up. Should the patient present as a repeat admission, with information obtained by the admitting group indicating there is an advance directive in the previous medical record, the nursing staff ewill have the responsibility to review the existing advance directive with the patient/significant other to validate its current status. The medical record from the previous admission containing the advanced directive will be identified with a red divider labeled advance directive. In the event that the patient/significant other indicates that the previous advance directive does not accurately reflect the patient s wishes, a revised advance directive must be submitted and must meet all advance directive regulations. Any expression by the patient of a revision in previous advance directive desires will be documented by the nursing personnel in the nursing progress notes.

65 PALO VERDE HOSPITAL Title: Advance Directives Policy Number: 16.0 Page 3 of 3 To the extent that the patient/significant other requests additional information or further explanation regarding the PSDA or advanced directives, referrals will be made to Pastoral Care and/or Social Services for follow-up interaction with patient and significant others, as appropriate. Should the patient wish to formulate an advance directive while receiving services in this institution, the Social Services Department will be contacted to assist the patient or refer the patient as necessary to accomplish the desire to formulate the directives. There will be availability of the Ethics Committee to discuss patient rights issues as needed, through the Medical Staff Office. All requests from patients/significant others, hospital personnel and/or medical staff members to institute the Ethics Committee process will be honored. All follow-up education and interaction with the patient/significant other will be documented in the medical record by the individual designated to interact with the patient/significant other regarding their concerns surrounding advance directives. In order to ensure that an opportunity for patient participation in medical decision making is maximized and that care provider is consistent with patient values and directives, educational information about advanced directives will be provided. Palo Verde Hospital s policies, mission and value statements regarding advance directives and withholding of life sustaining measures on a periodic basis and as necessary. Information will be provided through a collaborative effort with all disciplines via inservice format as well as written newsletter, memorandums, orientation process, annual personnel reviews and through the Advanced Directive Task Force Members. In order to assure that the community is served by this organization, education concerning advance directives and the PSDA shall be provided through community forums or written material made available at Palo Verde hospital. References: Protection and Advocacy System (state specific), The Nation s Voice on Mental Illness (NAMI), Clinical Nursing Skills, Basic to Advanced Skills, 7 th Edition, 2008, Sandra F. Smith, RN, MS, ABD; Donna J. Duell, RN, MS, ABN; Barbara C. Martin, RN, MS, CS Forms:

66 HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY EMSA #111 B (Effective 4/1/2011) A Check One B Check One C Check One D Physician Orders for Life-Sustaining Treatment (POLST) First follow these orders, then contact physician. This is a Physician Order Sheet based on the person s current medical condition and wishes. Any section not completed implies full treatment for that section. A copy of the signed POLST form is legal and valid. POLST complements an Advance Directive and is not intended to replace that document. Everyone shall be treated with dignity and respect. CARDIOPULMONARY RESUSCITATION (CPR): Patient Last Name: Patient First Name: Patient Middle Name: Date Form Prepared: Patient Date of Birth: Medical Record #: (optional) If person has no pulse and is not breathing. When NOT in cardiopulmonary arrest, follow orders in Sections B and C. Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B) Do Not Attempt Resuscitation/DNR (Allow Natural Death) MEDICAL INTERVENTIONS: If person has pulse and/or is breathing. Comfort Measures Only Relieve pain and suffering through the use of medication by any route, positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Transfer to hospital only if comfort needs cannot be met in current location. Limited Additional Interventions In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care. Transfer to hospital only if comfort needs cannot be met in current location. Full Treatment In addition to care described in Comfort Measures Only and Limited Additional Interventions, use intubation, advanced airway interventions, mechanical ventilation, and defibrillation/ cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care. Additional Orders: ARTIFICIALLY ADMINISTERED NUTRITION: Offer food by mouth if feasible and desired. No artificial means of nutrition, including feeding tubes. Additional Orders: Trial period of artificial nutrition, including feeding tubes. Long-term artificial nutrition, including feeding tubes. INFORMATION AND SIGNATURES: Discussed with: Patient (Patient Has Capacity) Legally Recognized Decisionmaker Advance Directive dated available and reviewed Advance Directive not available No Advance Directive Health Care Agent if named in Advance Directive: Name: Phone: Signature of Physician My signature below indicates to the best of my knowledge that these orders are consistent with the person s medical condition and preferences. Print Physician Name: Physician Phone Number: Physician License Number: Physician Signature: (required) Date: Signature of Patient or Legally Recognized Decisionmaker By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form. Print Name: Relationship: (write self if patient) Signature: (required) Date: Address: Daytime Phone Number: Evening Phone Number: SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

67 HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY Patient Information Name (last, first, middle): Date of Birth: Gender: M F Health Care Provider Assisting with Form Preparation Name: Title: Phone Number: Additional Contact Name: Relationship to Patient: Phone Number: Completing POLST Directions for Health Care Provider Completing a POLST form is voluntary. California law requires that a POLST form be followed by health care providers, and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by a physician who will issue appropriate orders. POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts. POLST must be completed by a health care provider based on patient preferences and medical indications. A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, or person whom the patient s physician believes best knows what is in the patient s best interest and will make decisions in accordance with the patient s expressed wishes and values to the extent known. POLST must be signed by a physician and the patient or decisionmaker to be valid. Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy. Certain medical conditions or treatments may prohibit a person from residing in a residential care facility for the elderly. If a translated form is used with patient or decisionmaker, attach it to the signed English POLST form. Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. A copy should be retained in patient s medical record, on Ultra Pink paper when possible. Using POLST Any incomplete section of POLST implies full treatment for that section. Section A: 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. Section B: 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). Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations. IV antibiotics and hydration generally are not Comfort Measures. Treatment of dehydration prolongs life. If person desires IV fluids, indicate Limited Interventions or Full Treatment. Depending on local EMS protocol, Additional Orders written in Section B may not be implemented by EMS personnel. Reviewing POLST It is recommended that POLST be reviewed periodically. Review is recommended 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. Modifying and Voiding POLST A patient with capacity can, at any time, request alternative treatment. A patient with capacity can, at any time, revoke a POLST 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. A legally recognized decisionmaker may request to modify the orders, in collaboration with the physician, based on the known desires of the individual or, if unknown, the individual s best interests. This form is approved by the California Emergency Medical Services Authority in cooperation with the statewide POLST Task Force. For more information or a copy of the form, visit SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

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