MDHHS-5836, MICHIGAN PHYSICIAN ORDERS

FOR SCOPE OF TREATMENT (MI-POST)

Michigan Department of Health and Human Services (MDHHS)

(Revised 8-22)

HIPAA permits disclosure of MI-POST to other Health Care Professionals, as necessary. This MI-POST form is void if Part 1 or Section D are blank. Leaving blank any section of the medical orders (Sections A, B, or C) does not void the form and is interpreted as full treatment for that section.

part 1 – PATIENT INFORMATION

Patient Last Name	Patient First Name	Patient Middle Initial

Date of Birth (mm/dd/yyyy)	Date Form Prepared (mm/dd/yyyy)

Diagnosis supporting use of MI-POST

This form is a Physician Order sheet based on the medical conditions and decisions of the person identified on this form. Paper copies, facsimiles, and digital images are valid and should be followed as if an original copy. This form is for adults with an advanced illness. It is not for healthy adults.

part 2 – medical orders

Section A – Cardiopulmonary Resuscitation (CPR) Person has no pulse and is not breathing. See MDHHS-5837 for further details.

Attempt Resuscitation/CPR (Must choose Full Treatment in Section B). DO NOT attempt Resuscitation/CPR (No CPR, allow Natural Death).

Section B – Medical Interventions Person has pulse and/or is breathing. See MDHHS-5837 for further details on medical interventions.

Comfort-Focused Treatment

Primary goal of maximizing comfort. May include pain relief through use of medication, positioning, wound care, food and water by mouth, and non-invasive respiratory assistance.

Selective Treatment

Primary goal of treating medical conditions while avoiding burdensome measures. May include IV fluids, cardiac monitoring including cardioversion, and non-invasive airway support.

Full Treatment

Primary goal of prolonging life by all medically effective means. May include intubation, advanced invasive airway interventions, mechanical ventilation, other advanced interventions.

Section C – Additional Orders (optional) Medical orders for whether or when to start, withhold, or stop a specific treatment. Treatments may include but are not limited to dialysis, medically assisted provisions of nutrition, long-term life-support, medications, and blood products.

Send form with Patient whenever transferred or discharged.
Section D – Signature of Attending Health Professional My signature below indicates that these orders are medically appropriate given the patient’s current medical condition, reflect to the best of my knowledge the patient’s goals for care, and that the patient (or the patient representative) has received the information sheet.

Print Name	Date

Signature	Phone Number

Print Name of Collaborating Physician	Phone Number

Section E – Signature of Patient or Patient Representative My signature indicates I have discussed, understand, and voluntarily consent to the medical orders on this MI-POST form. I acknowledge that if I am signing as the patient’s representative, these decisions are consistent with the patient’s wishes to the best of my knowledge.

Patient Patient Advocate/Durable Power of Attorney for Health Care (DPOAHC) Court-Appointed Guardian

Print Name of Patient	Print Name of Patient Representative

Signature	Date

Information of Legally Authorized Representative Complete this section if this MI-POST form was signed by a Patient Advocate/DPOAHC or Court-Appointed Guardian.

Address	City	State	Zip Code

Phone Number	Alternate Phone Number

Section F – Individual Assisting with Completion of MI-POST Form

Print Preparer’s Name	Title	Date

Preparer’s Signature	Organization	Phone Number

Section G – To Reaffirm or Revoke this Form This MI-POST form can be reaffirmed or revoked at any time, verbally or in writing. See MDHHS-5837 for further details on reaffirmation or revocation. If this document is revoked or is not reaffirmed, and a new form is not completed, full treatment and resuscitation will be provided.

Healthcare Provider Name/Collaborative Physician (if applicable)	Healthcare Provider Signature

Patient/Representative Name	Patient/Representative Signature	Reaffirmation Date

Send form with Patient whenever transferred or discharged. HIPAA permits disclosure of MI-POST to other Health Care Professionals, as necessary.

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.