HIPAA PERMITS DISCLOSURE OF IPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Last Name
Iowa Physician Orders
for Scope of Treatment
(IPOST)
First follow these orders, THEN contact the physician,
First/Middle Name
nurse practitioner or physician’s assistant. This is a
medical order sheet based on the person’s current
medical condition and treatment preferences. Any
section not completed implies full treatment for that
Date of Birth
section. Everyone shall be treated with dignity and
respect.
A
C
R
(CPR):
Person has no pulse AND is not breathing.
ARDIOPULMONARY
ESUSCITATION
Check
CPR/Attempt Resuscitation
one
DNR/Do Not Attempt Resuscitation
B
MEDICAL INTERVENTIONS:
Person has a pulse AND/OR is breathing.
COMFORT MEASURES ONLY Use medication by any route, positioning, wound care and
other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of
Check
airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-
one
sustaining treatment. Transfer if comfort needs cannot be met in current location.
LIMITED ADDITIONAL INTERVENTIONS Includes care described above. Use medical
treatment, cardiac monitor, oral/IV fluids and medications as indicated. Do not use intubation,
or mechanical ventilation. May consider less invasive airway support (BiPAP, CPAP). May use
vasopressors. Transfer to hospital if indicated, may include critical care.
FULL TREATMENT Includes care described above. Use intubation, advanced airway
interventions, mechanical ventilation and cardioversion as indicated. Transfer to hospital if
indicated. Includes critical care.
Additional Orders: ________________________________________________________
C
ARTIFICIALLY ADMINISTERED NUTRITION
Always offer food by mouth if feasible.
No artificial nutrition by tube.
Check
Defined trial period of artificial nutrition by tube.
one
Long-term artificial nutrition by tube.
D
MEDICAL DECISION MAKING
Directed by:
Rationale for these orders:
(listed in order of Iowa Code/Statute for
(check all
Priority of Surrogates; check only one)
that apply)
Patient
Advance Directives
Durable Power of Attorney for Health Care
Patient’s known preference
Spouse
Limited treatment options
Majority of Adult Children
Poor prognosis
Parents
Other: ________________________
Majority rule for nearest relative
Other: ____________________________
Physician/ARNP/PA signature
Print Physician/ARNP/PA Name
Date
Phone Number
(mandatory)
Patient/Resident or Legal Surrogate for Health Care Signature as identified above
Date
(mandatory)
SEND IPOST WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
DOCUMENT THAT IPOST FORM WAS TRANSFERRED WITH PERSON
HIPAA PERMITS DISCLOSURE OF IPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Last Name
Iowa Physician Orders
for Scope of Treatment
(IPOST)
First follow these orders, THEN contact the physician,
First/Middle Name
nurse practitioner or physician’s assistant. This is a
medical order sheet based on the person’s current
medical condition and treatment preferences. Any
section not completed implies full treatment for that
Date of Birth
section. Everyone shall be treated with dignity and
respect.
A
C
R
(CPR):
Person has no pulse AND is not breathing.
ARDIOPULMONARY
ESUSCITATION
Check
CPR/Attempt Resuscitation
one
DNR/Do Not Attempt Resuscitation
B
MEDICAL INTERVENTIONS:
Person has a pulse AND/OR is breathing.
COMFORT MEASURES ONLY Use medication by any route, positioning, wound care and
other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of
Check
airway obstruction as needed for comfort. Patient prefers no transfer to hospital for life-
one
sustaining treatment. Transfer if comfort needs cannot be met in current location.
LIMITED ADDITIONAL INTERVENTIONS Includes care described above. Use medical
treatment, cardiac monitor, oral/IV fluids and medications as indicated. Do not use intubation,
or mechanical ventilation. May consider less invasive airway support (BiPAP, CPAP). May use
vasopressors. Transfer to hospital if indicated, may include critical care.
FULL TREATMENT Includes care described above. Use intubation, advanced airway
interventions, mechanical ventilation and cardioversion as indicated. Transfer to hospital if
indicated. Includes critical care.
Additional Orders: ________________________________________________________
C
ARTIFICIALLY ADMINISTERED NUTRITION
Always offer food by mouth if feasible.
No artificial nutrition by tube.
Check
Defined trial period of artificial nutrition by tube.
one
Long-term artificial nutrition by tube.
D
MEDICAL DECISION MAKING
Directed by:
Rationale for these orders:
(listed in order of Iowa Code/Statute for
(check all
Priority of Surrogates; check only one)
that apply)
Patient
Advance Directives
Durable Power of Attorney for Health Care
Patient’s known preference
Spouse
Limited treatment options
Majority of Adult Children
Poor prognosis
Parents
Other: ________________________
Majority rule for nearest relative
Other: ____________________________
Physician/ARNP/PA signature
Print Physician/ARNP/PA Name
Date
Phone Number
(mandatory)
Patient/Resident or Legal Surrogate for Health Care Signature as identified above
Date
(mandatory)
SEND IPOST WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED
DOCUMENT THAT IPOST FORM WAS TRANSFERRED WITH PERSON
Use of original form is strongly encouraged. Photocopies and Faxes of signed IPOST forms are legal and valid
HIPAA PERMITS DISCLOSURE OF IPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Information for Person named on this Form
Person’s Name (print) _______________________________
This form records your preferences for life-sustaining treatment in your current state of health. It can be
reviewed and updated by your health care professional at any time if your preferences change. If you are unable
to make your own health care decisions, the orders should reflect your treatment preferences as best
understood by your surrogate.
Contact Information
Surrogate (optional)
Relationship
Phone Number
Directions For Health Care Professionals
Completing IPOST
Must be completed by a health care professional based on patient treatment preferences and medical
indications.
IPOST must be signed by a physician, nurse practitioner or physician’s assistant to be valid. Verbal
orders are acceptable with follow-up signature by physician, nurse practitioner or physician’s assistant in
accordance with facility/community policy.
Use of original form is strongly encouraged. Photocopies and FAXes of signed IPOST forms are legal
and valid.
Using IPOST
Any section of the IPOST not completed implies full treatment for that section.
A semi-automatic external defibrillator (AED) should not be used on a person who has chosen “Do Not
Attempt Resuscitation” unless otherwise specified.
Deactivation of internal defibrillators if comfort measures only are in effect.
Medications by alternative routes of administration to enhance comfort may be appropriate for a person
who has chosen “Comfort Measures Only.”
Voiding IPOST
A person with capacity, or the valid surrogate of a person without capacity, can void the form and
request alternative treatment.
To void this form, draw line through sections A through C and write “VOID” in large letters across the
form and sign and date that line if IPOST is replaced or becomes invalid.
Any changes require a new IPOST.
Transferring/Discharging with IPOST
The IPOST form belongs to the person.
The IPOST form MUST accompany the person upon all transfers between care settings.
Document that the IPOST was sent with the person.
Recommended use at home: Advise patient they must keep IPOST in easily accessible location that the
ambulance service could find if no family or friends present (example may be in an envelope or baggie
on the refrigerator).
Reviewing IPOST
This IPOST should be reviewed periodically whenever:
1. The person is transferred from one care setting or care level to another, or
2. There is a substantial change in the person’s health status, or
3. The person’s treatment preferences change.
Reviewed by:
Date:
Reviewed by:
Date:
Reviewed by:
Date:
Prepared by:
Health Care Professional Preparing Form
Preparer Title
Phone Number
Date Prepared
ORIGINAL TO ACCOMPANY PERSON IF TRANSFERRED OR DISCHARGED
DOCUMENT THAT IPOST FORM WAS TRANSFERRED WITH PERSON
Revised 01/21/09, 1/30/09, 07/6/09, 8/3/10, 6/25/12
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