POLST and MOLST Documentation Tracker

Inspection template for nursing homes to confirm POLST and MOLST forms are properly signed, current, accessible, and aligned with resident care plans. Supports regulatory compliance and survey readiness.

Inspection Details

• Facility name
  Enter the full legal name of the facility being reviewed.
• Facility license / provider number
  State-issued license or Medicaid/Medicare provider number.
• Date of review
  Date on which this documentation review is being conducted.
• Reviewer name and title
  Full name and professional title of the person conducting the review (e.g., DON, Compliance Officer, Charge Nurse).
• Resident identifier (room/unit or ID — do NOT enter full name or SSN)
  Enter room number, unit, or anonymized resident ID. Do not record full name or Social Security number in this field.
• Form type on file for this resident
  Select the advance directive order form type applicable to this resident's state and facility.

Form Presence and Currency

• POLST/MOLST form is present in the resident's active medical record
  Physically confirm the original or a facility-approved copy of the form is filed in the designated location within the chart or EHR.
• Form is the current state-approved version
  Verify the form version matches the most recently released state-approved template. NY DOH released an updated MOLST form — confirm the facility is not using a superseded version. (Source: leadingageny.org — Updated MOLST Form and Guidance Documents Released)
• Form was completed or reviewed within the past 12 months OR upon a significant change in condition
  Confirm the form date or most recent review date. A significant change in condition (e.g., new diagnosis, hospitalization, change in goals of care) should trigger re-review regardless of elapsed time.
• Date of most recent form completion or review
  Enter the date shown on the form or the date of the most recent documented review.

Signature and Authorization Completeness

• Physician, APRN, or PA signature is present and legible
  Confirm the ordering clinician's signature, printed name, and date are present in the designated signature block. Verify the clinician is licensed and authorized under state law to sign this order type.
• Resident or legally authorized representative (LAR) signature or documented consent is present
  Confirm the resident signed, or if the resident lacks decision-making capacity, that the LAR (healthcare proxy, legal guardian, or next of kin per state hierarchy) signed. If verbal consent was obtained, confirm it is documented per facility policy.
• If signed by LAR: relationship and authority documented in the record
  If the form was signed by a surrogate, confirm that documentation of the surrogate's authority (e.g., healthcare proxy designation, guardianship order) is present in the medical record.
• All signature fields are dated
  Confirm that both the clinician and resident/LAR signature blocks include a date. Undated signatures may render the form invalid.

Form Content and Treatment Order Accuracy

• CPR preference section (Section A) is completed and clearly marked
  Confirm that the CPR/DNR preference box is checked and unambiguous. A blank CPR section defaults to full resuscitation in most states — flag any blank or ambiguous entry.
• Medical interventions section (Section B) is completed
  Confirm that the level of medical intervention (comfort measures only, limited interventions, or full treatment) is clearly selected.
• Artificially administered nutrition section (Section C) is completed
  Confirm that the artificial nutrition preference is documented. If the resident has a feeding tube or PEG, verify consistency between this section and the care plan.
• Treatment orders are internally consistent (no contradictory instructions across sections)
  Review all sections together. Example of contradiction: DNR checked in Section A but 'full treatment including intubation' selected in Section B. Flag any inconsistencies for clinician review.

Accessibility and Care Plan Alignment

• Form is accessible at the point of care (e.g., front of chart, EHR alert, bedside binder) without requiring a search
  Simulate an emergency scenario: can staff locate the form within 60 seconds? Confirm the form location follows facility policy and is known to unit staff.
• Resident's care plan reflects the treatment preferences documented on the POLST/MOLST
  Cross-reference the care plan goals and orders against the POLST/MOLST. Discrepancies between the form and the care plan must be reconciled and documented.
• Transfer documentation (e.g., transfer form, EMS packet) references or includes the POLST/MOLST
  Confirm that if the resident is transferred to a hospital or other facility, the POLST/MOLST accompanies the resident per state policy.

Deficiencies, Corrective Actions, and Sign-Off

• Total number of deficiencies identified during this review
  Enter the count of items marked 'No' or flagged during this review.
• Deficiency summary and corrective action plan
  For each deficiency, describe: (1) the specific finding, (2) the responsible party for correction, and (3) the target completion date. Example: 'Section B blank — DON to contact attending physician Dr. [X] for completion by [date].'
• Photo evidence of form (redacted of PHI where required by facility policy)
  Attach a photo of the completed form if required by facility audit policy. Ensure any photo complies with HIPAA minimum necessary standards.
• Reviewer attestation signature
  By signing, the reviewer attests that this inspection was conducted accurately and completely to the best of their knowledge.