POLST cover sheet for an RCFE

In response to increasing concerns regarding how POLST is being administered in some assisted living communities and skilled-nursing facilities, the Coalition for Compassionate Care of California partnered with the California Association of Health Facilities (CAHF) and California Assisted Living Association (CALA) to develop provider-specific one-page POLST cover sheets entitled Key Facts about POLST for Residents and Family Members.

The cover sheets address key misconceptions regarding POLST, including whether completion of the form is voluntary – it is – and whether the POLST should be included with admission materials – it should not.

The cover sheet can be photocopied on standard white paper, and it should be paper-clipped, not stapled, to the uncompleted POLST form, and removed if and when the form has been completed and signed.

Because the POLST is voluntary and requires an in-depth conversation between patients and physicians, CCCC advises against facilities routinely including the POLST form with admission materials. When the POLST form is provided to residents in the assisted living or skilled-nursing facility setting, the appropriate POLST cover sheet should always be provided.

Bulk copies of the 2014 POLST form can be ordered through Med-Pass. Copies of the RCFE and SNF POLST cover sheets can be downloaded from caPOLST.org.

View and download the cover sheets

Signed by both a doctor and the patient, POLST is a physician order that specifies the types of medical treatment a patient wishes to receive or not receive toward the end of life.

POLST is more than a form – it is a tool that encourages conversation between providers and patients about their end-of-life treatment options and helps individuals make more informed decisions and communicate their wishes clearly.


Kelley Queale is a program director for the Coalition for Compassionate Care of California.

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