Medical orders for scope of treatment forms - form contents

(1) A medical orders for scope of treatment form must include the following information concerning the adult whose medical treatment is the subject of the medical orders for scope of treatment form: (a) The adult's name, date of birth, and sex; (b) The adult's eye and hair color; (c) The adult's race or ethnic background; (d) If applicable, the name of the hospice program in which the adult is enrolled; (e) The name, address, and telephone number of the adult's physician, advanced practice registered nurse, or physician assistant; (f) The adult's signature or mark or, if applicable, the signature of the adult's authorized surrogate decision-maker; (g) The date upon which the medical orders for scope of treatment form was signed; (h) The adult's instructions concerning: (I) The administration of CPR; (II) Other medical interventions, including but not limited to consent to comfort measures only, transfer to a hospital, limited intervention, or full treatment; and (III) Other treatment options; (i) The signature of the adult's physician, advanced practice registered nurse, or physician assistant.