🩺

Georgia POLST Form

This tool is for authorized clinical staff only. Please enter your access password to continue.

PMedGeorgia.com — Authorized clinical staff only

Step 1 of 7 — Patient information

Patient

Patient Information

Verify with patient or surrogate before completing.

Last name *

First name *

Middle initial

Date of birth *

Gender

Step 2 of 7 — CPR orders

⚠️ These are MEDICAL ORDERS. Physician co-signature required for legal validity in Georgia.

Section A

Cardiopulmonary Resuscitation (CPR)

If patient has no pulse and is not breathing.

Attempt Resuscitation / CPR

Full effort: chest compressions, defibrillation, intubation.

Do Not Attempt Resuscitation (DNR/DNAR)

Allow natural death. No compressions, defibrillation, or intubation.

Step 3 of 8 — Medical interventions

Section B

Medical Interventions

If patient has a pulse and/or is breathing but condition is serious.

Comfort Measures Only

Maximize comfort through symptom management. Transfer only if comfort cannot be achieved in current setting.

Limited Additional Interventions

Basic treatments, IV fluids, cardiac monitoring. No intubation. Avoid ICU when possible.

Full Treatment

All appropriate interventions including ICU care, mechanical ventilation, and advanced procedures.

Additional Orders (e.g. dialysis)

Step 4 of 8 — Antibiotics

Section C

Antibiotics

Select one option for antibiotic use.

No antibiotics

Use other measures to relieve symptoms.

Determine use or limitation of antibiotics when infection occurs

Use antibiotics if life can be prolonged

Additional Orders

Step 5 of 8 — Artificially administered nutrition & fluids

Section D

Artificially Administered Nutrition/Fluids

Always offer food and fluid by mouth if desired and safe.

Tube Feeding

No artificial nutrition by tube

Trial period of artificial nutrition by tube

Long-term artificial nutrition by tube

Additional Orders (tube feeding)

IV Fluids

No IV fluids

Trial period of IV fluids

Long-term IV fluids

Additional Orders (IV fluids)

Step 6 of 8 — Goals & discussion

Discussion

Goals of Care & Discussion

Patient's stated goals or values

Who participated in discussion? *

Patient (with decision-making capacity)

Health Care Agent / Proxy

Legally Authorized Representative

Court-Appointed Guardian

Surrogate / Representative name (if applicable)

Surrogate relationship

Clinician

Completing Clinician

Your full name *

Role / Title

Date completed *

Step 7 of 8 — Signatures

✍️ Hand the device to the patient or surrogate to sign. Then sign yourself as the clinician.

Signature

Patient / Surrogate Signature

Confirms these orders reflect their wishes.

Print name of signer

Relationship (if surrogate)

Patient / Surrogate — sign below

Sign here with finger or stylus

Clinician — sign below

Sign here with finger or stylus

Step 8 of 8 — Review & send

Summary

Review Before Sending

🔒 Review all orders carefully. Your electronic signature makes this a legally binding medical order in Georgia.

Orders

Orders to Co-sign

SECTION A — CPR

SECTION B — MEDICAL INTERVENTIONS

SECTION C — NUTRITION

Details

Form Details

Prior Signatures

Patient & Nurse Signatures

PATIENT / SURROGATE

CLINICIAN

Your Signature

Physician Co-signature

By signing you confirm these are your medical orders.

Your name (as it will appear on the form) *

License number

Phone number

Date signed

Physician signature — sign below

Sign here with finger or stylus

Georgia POLST Form

Georgia POLST Form

Patient Information

Cardiopulmonary Resuscitation (CPR)

Medical Interventions

Antibiotics

Artificially Administered Nutrition/Fluids

Goals of Care & Discussion

Completing Clinician

Patient / Surrogate Signature

Review Before Sending

POLST — Physician Review

Patient Name

Orders to Co-sign

Form Details

Patient & Nurse Signatures

Physician Co-signature