HIPAA PERMITS DISCLOSURE OF MOST
TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Medical Orders
for Scope of Treatment (MOST)
This is a Physician Order Sheet based on the patient’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 Last Name: Effective Date of Form:
Patient’s First Name, Middle Initial: Patient’s Date of Birth:
CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.
Attempt Resuscitation (CPR) Do Not Attempt Resuscitation (DNR/no CPR)
When not in cardiopulmonary arrest, follow orders in B, C, and D.
MEDICAL INTERVENTIONS: Patient 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.; also provide comfort measures. Transfer to hospital if indicated.
Limited Additional Interventions: Use medical treatment, IV fluids and cardiac monitoring as indicated.
Do not use intubation or mechanical ventilation. May consider use of less invasive airway support such as BiPAP or
CPAP. 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 to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed
for comfort. Do not transfer to hospital unless comfort needs cannot be met in current location.
Other Instructions
Section
C
Check One
Box Only
ANTIBIOTICS
Antibiotics if indicated
Determine use or limitation of antibiotics when infection occurs
No Antibiotics (use other measures to relieve symptoms)
Other Instructions
Section
D
Check One
Box Only in
Each
Column
MEDICALLY ADMINISTERED FLUIDS AND NUTRITION: Offer oral fluids and nutrition if
physically feasible.
IV fluids if indicated Feeding tube long-term if indicated
IV fluids for a defined trial period Feeding tube for a defined trial period
No IV fluids (provide other measures to ensure comfort) No feeding tube
Other Instructions
Section E
Check The
Appropriate
Box
DISCUSSED WITH
Patient Majority of patient’s reasonably available
AND AGREED TO BY:
Parent or guardian if patient is a minor parents and adult children
Health care agent Majority of patient’s reasonably available
Legal guardian of the patient adult siblings
Basis for order must be
Attorney-in-fact with power to make An individual with an established relationship
documented in medical health care decisions with the patient who is acting in good faith and
record.
Spouse
can reliably convey the wishes of the patient
MD/DO, PA, or NP Name (Print):
MD/DO, PA, or NP Signature and Date (Required):
Phone #:
Signature of Patient, Parent of Minor, Guardian, Health Care Agent, Spouse, or Other Personal Representative
(Signature is required and must either be on this form or on file)
I agree that adequate information has been provided and significant thought has been given to life-prolonging measures.
Treatment preferences have been expressed to the physician (MD/DO), physician assistant, or nurse practitioner. This
document reflects those treatment preferences and indicates informed consent.
If signed by a patient representative, preferences expressed must reflect patient’s wishes as best understood by that
representative. Contact information for personal representative should be provided 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 Signature Relationship (write “self” if patient)
SEND FORM WITH PATIENT/RESIDENT WHEN TRANSFERRED OR DISCHARGED
Section
A
Check One
Box Only
Section
B
Check One
Box Only
