KATIE ADULT DAY CENTER POLICIES AND PROCEDURES

SUBJECT: POLST ORDERS

Reference: Recommended but not required

Document Number: 05-035.16

POLICY: Our ADS works with our participants, their representatives, and their
attending health care providers such as nurse practitioners and
physicians to provide services consistent with the POLST orders.

PROCEDURE:

1. POLST orders are orders written by the client attending physician/nurse practitioner on
a standardized form after the health care provider (physician/NP) has been authorized
to do so by the person/representative(s). POLST orders include orders to be followed by
emergency responders, and other providers such as emergency room services, in the
event of urgent or emergency medical situations occur for the client. POLST is an
acronym for Provider Orders for Life Sustaining Treatment.

2. When a client is admitted as an ADS participant, the participant/representative(s) and, if

necessary, the clients attending health care provider(s) (physician/NP) are asked if the
participant has previously authorized POLST orders. If the participant has previously
authorized POLST orders, the nurse or ADS Director requests a copy for the clients file.

3. If the client has not previously authorized POLST orders, information about POLST is
provided.

4. Whether received at admission or at any time thereafter, the RN reviews the content of
any POLST orders received to:
a. determine what the orders include;
b. determine if they must be updated by the clients attending health provider in order
to be current;
c. ensure that POLST orders are incorporated during all processes related to service
plan development and emergency responses.
d. The POLST form is signed by a physician
5. The RN documents the POLST orders in the client record. The POLST orders are included
in the client record in such a way that they are readily accessible and retrievable during
a medical emergency and so that they are utilized during all processes related to service
plan development for the person.

Katie Adult Day Center Policies and Procedures Manual 05-035.16

6. The RN conducts appropriate follow-up with the participant/representative(s), and the
clients attending health care provider(s) to obtain updated POLST orders if necessary, if
the clients expressed wishes appear to change or if the clients condition significantly
changes.
7. The POLST document is not required otherwise to be updated. The physician signed
POLST document must be available for emergency services to follow the clients
preferences.
8. If the client is transferred to another health care setting on an emergency basis from the
ADS, our center provides a copy of the most recent POLST orders.

[Note: ADS providers should periodically check the POLST website at

http://www.mnmed.org/KeyIssues/POLSTCommunications/tabid/3291/Default.aspx to see if
the form has been revised.]

Katie Adult Day Center Policies and Procedures Manual 05-035.16