Exit this survey Maryland MOLST Participant 100% of survey complete. Question Title * 1. Maryland MOLST is a portable and enduring medical order form that contains orders about cardiopulmonary resuscitation and other life-sustaining treatments that becomes effective on: July 1, 2011 October 1, 2011 January 1, 2012 April 1, 2012 Question Title * 2. A patient has the right to decline to discuss these topics. If the patient makes no decision about CPR or declines to discuss CPR, then: leave Section 1 on the MOLST form blank using the best interest standard, chose a code status for the patient mark “Attempt CPR” on the first page of the MOLST form, unless CPR is medically ineffective insist that the patient make a decision at this time Question Title * 3. When a Maryland MOLST order form is completed: do not provide the patient with a copy provide a copy to the patient after a privacy release form is completed provide the patient with a copy within 48 hours or sooner if the patient is transferred or discharged provide the patient with a copy upon transfer or discharge from the facility or program Question Title * 4. Maryland MOLST: rescinds the Health Care Decisions Act invalidates an individual’s advance directive allows a physician or nurse practitioner to make health care decisions for a competent patient contains orders based on an informed discussion with a patient or authorized decision maker Question Title * 5. A patient has the right to make his or her own health care decisions: until physicians certify that he or she lacks the capacity to make health care decisions until he or she is 75 years or older only if he or she agrees with the doctor’s recommendations until he or she has a terminal illness with an expected life expectancy of six months or less Question Title * 6. The Maryland MOLST order form replaces the: facility admissions contract and the patient’s advance directives EMS DNR form and Life Sustaining Treatment Options form EMS DNR form and the HIPAA release form advance directives and HIPAA release form Question Title * 7. When Maryland MOLST becomes effective, it must be completed for every patient admitted to: an ambulatory surgery center a free-standing emergency department an assisted living facility a residential service agency Question Title * 8. A Maryland MOLST order form is valid when: any licensed individual signs and dates the order form a licensed physician or nurse practitioner signs and dates the order form as well as listing his or her Maryland license number and phone number the order is less than one year old a licensed physician or nurse practitioner signs and dates the order form Question Title * 9. A competent individual may: complete and sign his or her own Maryland MOLST order form always receive a copy of his or her Maryland MOLST order form within one hour of it being completed agree or disagree with a treatment option make a physician or nurse practitioner order medically ineffective treatment Question Title * 10. The Maryland MOLST order form: must be printed on pink paper to be a valid order must be printed as a double sided form is not valid if it is a copy or a fax shall be kept with other active medical orders Done