Checklist for Minor Patients
MOLST Instructions and Legal Requirements Checklist for Minor Patients
The New York State Department of Health developed Medical Orders for Life-Sustaining Treatment (MOLST) instructions to aid physicians and health care professionals in using the MOLST form for minor patients. The MOLST Instructions include a checklist outlining the legal requirements for issuing orders to withhold or withdraw life-sustaining treatment using the MOLST.
NYSDOH MOLST Legal Requirements Checklist for Minor Patients
MOLST Chart Documentation Form for Minor Patients (align with NYSDOH Checklist)
- MOLST Chart Documentation Form for Minor Patients
NYS MOLST Form
- DOH-5003 MOLST form
- Printing the MOLST form on bright "pulsar" pink, heavy stock paper is strongly encouraged.
- Astrobrights Pulsar Pink 24lb paper is available through Office Depot, Staples, Office Max, and other paper suppliers.
- When EMS personnel respond to an emergency call in the community, they are trained to check whether the patient has a pink MOLST form before initiating
life-sustaining treatment. They might not notice a MOLST form on plain white paper.
- However, white MOLST forms and photocopies, faxes, or electronic representations of the original, signed MOLST are legal and valid.
- Spanish version of the DOH-5003 MOLST form is for educational purposes ONLY.
In This Section
- Advance Care Planning
- MOLST & FHCDA
- Statewide Implementation Team
- MOLST Discussion
- MOLST Form
- How to Complete
- Checklists for Adult Patients
- Checklist for Minor Patients
- Checklist for Patients with Developmental Disabilities
- Checklists for Patients in a Mental Hygiene Facility
- Capacity Determination
- Completed Forms
- When to Review
- MOLST Training Center
- Care Transitions Intervention
- Palliative Care
- Pain Management