POLST Clinical Workflow Development

This page describes the core POLST workflows your organization will need to design and implement. These workflows are provided as starting-point guidance — your team should adapt them to reflect your specific care settings, EHR environment, and existing processes.

How to use this page 

For each workflow, review the standard steps, then adapt and document your organization's customized version. Validate with frontline clinical staff before finalizing. Consider developing one-page job aids based on your finalized workflows for use at the point of care.

Workflow 1: POLST Initiation and Review

Ensure that patients who may benefit from a POLST are identified, have a meaningful goals-of-care conversation, and — if they choose — have a POLST completed and documented correctly.

Standard Steps

Step	Standard action	Your organization's version	Tips
Identify	Screen for patients who may be appropriate for POLST	Who screens patients? At what point in care? What criteria trigger the conversation?	Consider whether a care coordinator, or nurse could identify patients based on agreed-upon criteria. Define criteria explicitly: diagnosis groups, age thresholds, frequency of hospitalization, hospice enrollment.  Consider whether EHR can surface flags automatically (e.g., via diagnosis codes or problem list entries).
Prepare	Review the patient's health status, prognosis, and any existing advance directives before the conversation	Who reviews? What documentation is needed first? Are interpreters needed?	Include checking for advance directive, HCP, or existing MOLSTs or POLSTs before meeting with the patient. Consider patient needs for an interpreter.
Talk	Have a goals-of-care conversation with the patient (and Health Care Agent/family if present). Explore prognosis, what matters most, and treatment preferences in emergencies	Who leads the conversation?	The conversation leader doesn't have to be a doctor or advanced practice provider -  social workers, nurses, and pastoral care practitioners are often well-positioned by relationship and training. Map this step to your team's strengths and scope of practice. Determine whether co-leading makes sense in complex cases (e.g., palliative care plus primary care), and define what triggers co-leading. Decide how your team will handle HCA involvement.
Document	Document the conversation in the EHR, including key points discussed and patient decision. If the patient chooses not to have a POLST, document the reason why in a place that will be accessible in case the patient is re-admitted or their health status changes.	What is documented? Where in the EHR?	Establish a standard for what the note must include: who participated, key goals and preferences expressed, what was decided, and whether it aligns with existing advance directives.  Consider whether a documentation template or smart text would improve consistency and reduce burden across the team. Decide where conversation documentation lives in your EHR — a dedicated ACP section, an encounter note, or both.
Complete POLST	If the patient chooses to have a POLST, complete and sign the form in the ePOLST Registry. Print for the patient and confirm understanding.	Who enters information into the form? Who signs? What is printed and given to the patient?	Form information entry and signing can be split across roles — determine who is trained and authorized to enter information in the ePOLST Registry versus who must sign. Only MD, DO, NP, or PA can sign. Define what the patient receives at the end of the encounter: a printed copy, instructions on where to keep it, and an explanation of how the ePOLST Registry works.
Update EHR	Follow organizational policy to reflect POLST status in the EHR — code status, order sets, alerts	What is updated? Who is responsible?	EHR update and ePOLST Registry entry are two distinct actions — your workflow needs to account for both, and they may involve different people or systems. Identify everything that needs updating: code status, relevant order sets, problem list, and any alert or flag for care transitions.
Revisit	Revisit POLST when the patient's health status, goals, or preferences change. Update the registry and EHR if revisions are made	What triggers a review? Who is responsible?	Define triggers for POLST review explicitly — Consider: hospital admission or discharge, transition to a new care setting, a change in prognosis, or a patient-initiated request. Embed revisit prompts into existing workflows (e.g., discharge checklists, care plan reviews, annual wellness visits). Determine how your team communicates a POLST revision to downstream settings (e.g., a SNF or home health agency).

Workflow 2: POLST at Care Transitions

Ensure that a patient's POLST travels with them — in spirit and in practice — whenever they move between care settings.

Key transitions to address

• Hospital to skilled nursing facility or long-term care
• Hospital to home with home health
• Emergency department admission or discharge
• Primary care or outpatient to inpatient
• Within facility (e.g., ICU to floor or standard care to memory care)
• Between provider teams (e.g., hospitalist handoff)

Standard steps at transition

1. Check registry: Confirm current POLST status in ePOLST Registry before or at time of transfer

2. Communicate: Notify receiving team of POLST status — verbally and in transfer documentation

3. Share printed copy: Ensure the patient has their printed POLST and knows to keep it accessible

4. Verify in EHR: Confirm POLST is documented in the receiving care setting's EHR and code status is updated

5. Reassess when appropriate: Any significant change in health status at transition is an opportunity to revisit goals of care with patient

Workflow 3: Retrieving and Following POLST in Emergencies

Ensure that clinicians responding to a medical emergency can quickly find a patient's POLST and follow it correctly — even under time pressure.

Standard steps

1. Find POLST: Access ePOLST Registry to determine POLST status and/or find paper copy of POLST

2. Follow orders: Act in accordance with the POLST medical orders for resuscitation, medical interventions, and if applicable, nutrition

3. Engage Health Care Agent: Contact the patient's Health Care Agent or surrogate whenever feasible and appropriate

4. Document: Document that POLST was reviewed and followed in the clinical encounter record

5. Debrief if needed: If the care delivered may not have aligned with the POLST, debrief with the clinical team and notify the quality/compliance team