POLST and MOLST Documentation Tracker
Use this POLST and MOLST Documentation Tracker to verify each resident’s form is current, signed, accessible, and consistent with the care plan. It helps nursing homes catch missing signatures, outdated orders, and transfer packet gaps before survey day.
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Overview
This POLST and MOLST Documentation Tracker is an inspection-style audit for nursing homes and other long-term care settings that need to confirm a resident’s medical orders for life-sustaining treatment are complete and usable at the point of care. It walks the reviewer through the record in the same order a surveyor or care team member would expect to verify it: inspection details, form presence and currency, signature and authorization completeness, treatment order accuracy, accessibility, care plan alignment, and corrective action follow-up.
Use this template when you need to document that a POLST or MOLST form is the current state-approved version, was completed or reviewed within the expected timeframe, and is signed by the right clinician and resident or legally authorized representative. It is especially useful after admission, after a significant change in condition, during periodic compliance audits, and before transfers. The tracker also helps confirm that the resident’s care plan and transfer paperwork match the documented treatment preferences.
Do not use this as a substitute for clinical judgment or state-specific legal review. If your state has unique POLST or MOLST rules, the facility should adapt the checklist to match those requirements. It is also not the right tool for residents who do not have a POLST or MOLST order set in place; in those cases, use your advance directive or goals-of-care documentation process instead. Common pitfalls include outdated forms, missing authorization, contradictory orders across sections, and forms that exist in the chart but are not quickly accessible during an emergency.
Standards & compliance context
- This template supports nursing facility documentation practices that are commonly reviewed under CMS long-term care expectations and state survey processes.
- The form review aligns with POLST and MOLST program rules, which are state-specific and should be checked against the applicable state-approved form and guidance.
- Care plan alignment and record consistency support broader quality management expectations found in ISO 9001-style audit discipline and long-term care compliance programs.
- If the resident’s orders affect emergency response or transfer decisions, the facility should ensure the document is available to staff and included in handoff materials consistent with survey expectations.
- This tracker is not a legal determination of validity; if a signature, authority, or form version is in question, the facility should escalate to clinical leadership or legal/compliance review.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Inspection Details
This section establishes who reviewed the record, when the review happened, and which resident chart or unit was checked without exposing unnecessary personal data.
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Facility name
Enter the full legal name of the facility being reviewed.
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Facility license / provider number
State-issued license or Medicaid/Medicare provider number.
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Date of review
Date on which this documentation review is being conducted.
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Reviewer name and title
Full name and professional title of the person conducting the review (e.g., DON, Compliance Officer, Charge Nurse).
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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.
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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
This section confirms the resident has the correct, current POLST or MOLST form and that it was reviewed within the expected clinical timeframe.
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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.
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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)
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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.
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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
This section verifies that the orders are authorized by the right clinician and that resident or LAR consent is documented and dated.
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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.
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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.
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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.
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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
This section checks that the treatment preferences are fully completed and do not conflict across CPR, medical intervention, or nutrition orders.
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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.
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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.
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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.
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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
This section confirms staff can find the form quickly and that the care plan and transfer materials match the documented orders.
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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.
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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.
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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
This section turns the audit into action by recording gaps, assigning follow-up, and capturing reviewer attestation.
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Total number of deficiencies identified during this review
Enter the count of items marked ‘No’ or flagged during this review.
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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].’
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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.
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Reviewer attestation signature
By signing, the reviewer attests that this inspection was conducted accurately and completely to the best of their knowledge.
How to use this template
- 1. Enter the facility, reviewer, date, and resident identifier so the audit can be traced without using full names or other unnecessary PHI.
- 2. Verify that the resident has the current POLST or MOLST form in the active medical record and record the date of the most recent completion or review.
- 3. Check that the clinician signature, resident or LAR consent, relationship or authority, and all dates are present and legible.
- 4. Review each treatment section for completeness and confirm the orders do not conflict with one another or with the resident’s documented goals of care.
- 5. Confirm the form is easy to find at the point of care and that the care plan and transfer documents reflect the same treatment preferences.
- 6. Record every deficiency, assign corrective action, attach redacted evidence if permitted by policy, and complete reviewer sign-off.
Best practices
- Review the form against the current state-approved version before you judge completeness, because outdated templates can look valid while failing local requirements.
- Treat accessibility as a real compliance check: the form should be reachable in seconds in the chart, EHR, or bedside packet, not buried in scanned documents.
- Compare the POLST or MOLST orders against the care plan line by line so a no-CPR or limited-intervention preference is not contradicted elsewhere in the record.
- Flag any missing date, unclear signature, or undocumented LAR authority as a deficiency, even if the rest of the form appears complete.
- Use the resident’s most recent significant change in condition as a trigger for re-review, since orders can become outdated after a hospitalization or decline.
- Photograph or capture evidence only according to facility policy and always redact PHI when required before attaching it to the audit record.
- Document the exact location of the form in the EHR or paper chart so staff can find it quickly during an emergency or transfer.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
Who should use this POLST and MOLST Documentation Tracker?
This tracker is designed for nursing home administrators, MDS or care coordination staff, DONs, unit managers, and compliance reviewers. It works well when one person audits the record and another follows up on deficiencies. If your facility uses a different role for advance directive review, you can assign that reviewer here without changing the form structure.
How often should POLST and MOLST forms be reviewed?
A common cadence is at admission, after any significant change in condition, and during periodic chart audits. Many facilities also review these forms during care plan updates and before transfers. The tracker includes a date field so you can document whether the form is current within your facility’s review cycle.
Does this template apply to both POLST and MOLST forms?
Yes. The template is built to track either POLST or MOLST documentation, depending on the resident’s state-approved form and local practice. Because state programs differ, the tracker focuses on the shared compliance points: presence, currency, signatures, treatment orders, and accessibility. You can label the form type on file for each resident.
What regulatory or survey issues does this tracker help with?
It supports survey readiness by documenting whether the resident’s medical orders are present, legible, dated, and aligned with the care plan. It also helps facilities show that advance care planning documents are accessible at the point of care and available for transfers. The template is aligned with general nursing facility compliance expectations and state-specific POLST or MOLST program requirements.
What are the most common mistakes this audit catches?
The most common issues are missing signatures, outdated forms after a change in condition, and contradictory treatment instructions across sections. Facilities also miss cases where the form exists in the chart but is not easy to find during a shift or transfer. Another frequent gap is a care plan that does not match the resident’s documented preferences.
How does this template differ from an ad hoc chart check?
An ad hoc check usually confirms only that a form exists. This tracker forces a structured review of currency, authorization, content accuracy, accessibility, and care plan alignment in one pass. That makes it easier to assign corrective actions and show what was reviewed if a surveyor asks.
Can we customize this tracker for our state or facility workflow?
Yes. You can rename the form type field, add state-specific terminology, or expand the deficiency section to match your internal corrective action process. Facilities often add a field for electronic location, chart tab name, or transfer packet location. If your state has a preferred POLST/MOLST version, you can also add that version name to the review criteria.
How should this be integrated with EHRs or transfer packets?
Use the accessibility section to record where the form appears in the EHR and whether it is included in bedside or transfer materials. Many facilities pair this tracker with a chart audit log, care plan review, and transfer checklist. That way, the same review supports both daily care and emergency handoff readiness.
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