HOSPITAL CHART REVIEW FORM - POLST



OR HOSPITAL CHART REVIEW FORM

1. Today’s Date _________________________

2. Age in Years ________

3. Gender

( Female ( Male

4. Race/Ethnicity:

( White ( African American/Black ( Native Hawaiian/Pacific Islander ( Asian ( American Indian/Alaskan Native ( Hispanic ( Other ( not available

5. Education

( No Schooling ( 8th Grade/less ( 9 – 11th grades

( High School ( Technical/trade school ( some college

( Bachelor’s degree ( Graduate degree ( not available

6. Discharge destination

( Bethany St. Joseph’s ( Bethany Riverside ( Hillview

( St. Joseph’s ( Onalaska Care ( Mulders

( Lakeview ( Rolling Hills ( Morrow Home

7.Admission/Discharge:

a. Primary reason for hospitalization_____________________________________

b. Reason for discharge to nursing home

□ rehabilitation □ long term care □ other ___________

c. Is this a new discharge to a nursing home? □ yes □ no

d. Did the resident have a POLST at admission to the hospital? □ yes □ no

If the resident had a POLST at admission, was the POLST changed at discharge? ( yes ( no ( not applicable

8. Primary service admitted to:__________________________________________

Discharge Service: _________________________________________________

Date of admission_________________ Date of Discharge __________________

HOSPITAL PREFERENCES, ORDERS, & LIFE-SUSTAINING TREATMENTS

9. PREFERENCES: Is there evidence of a discussion about treatment preferences in the chart at discharge: □ yes □ no

If yes, describe:

|Date of Discussion |Staff involved? Identify. |Patient/family involved? Identify. |Was surrogate authorized? If so, |

| | | |describe role. |

| | | | |

| | | | |

| | | | |

a. Where is this documented? ______________________________________

b. Who documented the discussion? _________________________________

c. Length of discussion

□ 0-15 min. □ 15-30 min. □ 30-45 min □ no time listed

d. What was discussed? Please describe treatment preferences or plans.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. a. What, if any, advance directive forms are present in the chart? (Check all that apply)

❑ Advance directive/living will (circle type used and indicate date of document)

o LaCrosse Respecting Choices POAHC _____/_____/_______ Date

o Addendum to POAHC _____/_____/_______ Date

o Statement of Treatment Preference form _____/_____/_______ Date

o Wisconsin Statutory POAHC _____/_____/_______ Date

o Wisconsin Declaration to Physicians or

other Living Will _____/_____/_______ Date

❑ Designated Decision-maker (named by resident) _____/_____/_______ Date

❑ Legal Guardian _____/_____/_______ Date

❑ Other (describe) __________________________ _____/_____/_______ Date

❑ No form present

b. Who is making decisions at this point in time?

❑ Patient

❑ Healthcare Agent

❑ Legal Guardian

❑ Designated Decision-maker

❑ Next of kin

❑ Other:__________________________

11. Document all treatment preferences in the table below. (See advance directive)

| | |

|IF I AM CLOSE TO DEATH: |IF I AM PERMANENTLY UNCONSCIOUS/PERISTENT VEGETATIVE STATE: |

|I want feeding tubes/artificial nutrition and hydration. |I want to receive tube feeding |

|I want tube feedings only as my physician recommends |I want tube feeding only as my physician recommends |

|I do not want feeding tubes/artificial nutrition and hydration |I do not want tube feeding |

|No preference indicated |No preference indicated |

| | |

|I want any other life support that may apply |I want any other life support that may apply |

|I want life support only as my physician recommends |I want life support only as my physician recommends. |

|I want NO life support |I want NO life support |

|No preference indicated |No preference indicated |

|KIDNEY DIALYSIS |VENTILATOR SUPPORT |

|( I do want kidney dialysis |( I do want ventilator support |

|I do not want kidney dialysis |I do not want ventilator support |

|No preference indicated |No preference indicated. |

| | |

|RESUSCITATION (preferences, not orders) |LOSS OF ABILITY TO RELATE TO SELF, OTHERS AND ENVIRONMENT |

|( I do want cardiac resuscitation |I do not want CPR |

|I do not want cardiac resuscitation |I do not want antibiotics |

|I want CPR under certain circumstances as MD recommends |I do not want a feeding tube, artificial hydration and nutrition |

|No preference indicated |No preference indicated |

|ANTIBIOTICS |TRANSFUSION |

|( I do want antibiotics |( I do want transfusion |

|I do not want antibiotics |I do not want transfusion |

|No preference indicated |No preference indicated |

|PAIN AND SYMPTOM CONTROL IF EFFORTS TO PROLONG LIFE ARE STOPPED |HOSPITALIZATION |

|I want to be kept comfortable even if it risks my dying sooner |( I do want ____________________ |

|No preference indicated |( I do not want _________________ |

| |( No preference indicated |

|Agent authority to admit me to a nursing home or community-based |Agent authority to order the withholding or withdrawal of feeding tube|

|residential facility for the purpose of long-term care: |and IV hydration: |

|( Yes |( Yes |

|No |No |

| |

|OTHER PREFERENCES |

12. ORDERS RE LIFE-SUSTAINING TREATMENT: Document all medical orders written in the medical chart in the table below.

|TREATMENT CATEGORY | |WRITTEN ORDERS |DATE OF ORDER |

| |CHECK | | |

| |BOX | | |

|Resuscitation/ | |Full Code | |

|Medical | | | |

|Intervention | | | |

| | |O-DNR | |

| | |O-DNR/DNI | |

| | |P-DNR | |

|Other Orders (specify) | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

13. TREATMENTS: Document life-sustaining treatments below.

|TREATMENT PROVIDED |Date(s) of occurrences |Treatments Provided & |

| | |Other Relevant Information |

|Resuscitation: |1)____________ | |

| |2)____________ | |

|EMS visit with/without transport |1) ____________ |1) ____________ |

|(indicate treatments provided by EMS): |2) ____________ |2) ____________ |

| |3) ____________ |3) ____________ |

| |4) ____________ |4) ____________ |

|Emergency Department Visit without |1) ____________ |1) ____________ |

|hospitalization (indicate treatments provided in |2) ____________ |2) ____________ |

|ED): |3) ____________ |3) ____________ |

| |4) ____________ |4) ____________ |

|Hospitalization: |1) ____________ | |

| |2) ____________ | |

|Surgery: |1) ____________ | |

| |2) ____________ | |

|Transfusion: |1) ____________ | |

| |2) ____________ | |

| |3) ____________ | |

| |4) ____________ | |

|Intubation: |1) ____________ | |

| |2) ____________ | |

| |3) ____________ | |

| |4) ____________ | |

|Dialysis: |1) ____________ | |

| |2) ____________ | |

| |3) ____________ | |

| |4) ____________ | |

|Antibiotics: |1) ____________ | |

| |2) ____________ | |

| |3) ____________ | |

| |4) ____________ | |

|Feeding Tubes: |1) ____________ | |

| |2) ____________ | |

| |3) ____________ | |

| |4) ____________ | |

|IV Fluids: |1) ____________ | |

| |2) ____________ | |

| |3) ____________ | |

| |4) ____________ | |

|Chemotherapy: |1) ____________ | |

| |2) ____________ | |

| |3) ____________ | |

| |4) ____________ | |

|Ventilator/Respirator: |1) ____________ | |

| |2) ____________ | |

| |3) ____________ | |

| |4) ____________ | |

14. At discharge are there orders for life-sustaining treatment out in the community?

□ yes □ no

If yes, what type of orders?

□ Wisconsin DNR order form/bracelet _____/_____/_______ Date

□ POLST (Please document orders found on POLST below)

a. Is document signed? □ yes □ no

b. Is document dated? □ yes □ no

If yes, date signed: _____/_____/_______ Date

c. Is there a resident/surrogate signature on back? □ yes □ no

d. What parts of document have been completed?

□ A □ B □ C □ D □ E

15. POLST ORDERS AT DISCHARGE

|TREATMENT CATEGORY | |WRITTEN ORDERS |DATE OF ORDER |

| |CHECK | | |

| |BOX | | |

|A. Resuscitation | |DNR/DNAR | |

| | |Full Code | |

|B. Medical Interventions | |Comfort measures only….allow a natural death to occur | |

| | |Do not hospitalize | |

| | |Limited/advanced treatments | |

| | |Full treatment | |

|C. Antibiotics | |No antibiotics | |

| | |No IM/IV antibiotics | |

| | |Antibiotics | |

|D. Artificial Nutrition and | |No artificial nutrition or hydration | |

|Hydration | | | |

| | | Limited trial for _____ days | |

| | |Artificial nutrition and hydration | |

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