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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 critical (required)

Physically confirm the original or a facility-approved copy of the form is filed in the designated location within the chart or EHR.

Yes No N/A

Form is the current state-approved version critical (required)

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 NY DOH released an updated MOLST form — confirm the facility is not using a superseded version.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)

Yes No N/A

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.

Yes No N/A

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 critical (required)

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.

Yes No N/A

Resident or legally authorized representative (LAR) signature or documented consent is present critical (required)

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.

Yes No N/A

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.

Yes No N/A

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.

Yes No N/A

Form Content and Treatment Order Accuracy

CPR preference section (Section A) is completed and clearly marked critical (required)

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.

Yes No N/A

Medical interventions section (Section B) is completed critical (required)

Confirm that the level of medical intervention (comfort measures only, limited interventions, or full treatment) is clearly selected.

Yes No N/A

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.

Yes No N/A

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.

Yes No N/A

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 critical (required)

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.

Yes No N/A

Resident's care plan reflects the treatment preferences documented on the POLST/MOLST critical (required)

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.

Yes No N/A

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.

Yes No N/A

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.

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Run: POLST and MOLST Documentation Tracker

Inspection Details

Form Presence and Currency

Signature and Authorization Completeness

Form Content and Treatment Order Accuracy

Accessibility and Care Plan Alignment

Deficiencies, Corrective Actions, and Sign-Off

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