Compassion and Support


Patients & Families

Checklist for Adult Patients

MOLST Instructions and Legal Requirements Checklists for Adult Patients

The New York State Department of Health (NYSDOH) has developed MOLST instructions and checklists for adult patients setting forth the legal requirements for issuing orders with respect to life-sustaining treatment using the MOLST form for adult patients with respect to patient preferences for resuscitation and life-sustaining treatment.  Final December 2010 documents are posted on NYSDOH MOLST.

 Overview of MOLST Instructions and Checklists for Adult Patients - One page summary 

 MOLST General Instructions and Glossary [pdf]

Decision-making standards, procedures and statutory witness requirements for decisions to withhold or withdraw life-sustaining treatment, including DNR, for adult patients vary depending on who makes the decision and where the decision is made.  Accordingly, there are five different checklists for different types of decision-makers and settings.  These requirements must be followed with or without using the MOLST form.

NYSDOH MOLST Legal Requirements Checklists for Adult Patients

  1.  MOLST Checklist 1 - adult with capacity any setting
  2.  MOLST Checklist 2 - adult with health care proxy any setting
  3.  MOLST Checklist 3 - adult with FHCDA surrogate
  4.  MOLST Checklist 4 - adult without FHCDA surrogate 
  5.  MOLST Checklist 5 - adult without capacity in the community 

Documentation of the clinical process and legal requirements under FHCDA must be included in the medical record.  MOLST Chart Documentation Forms align with the NYSDOH Legal Checklists for Adults.  Completion of the appropriate form serves as documentation of both the conversation and the legal requirements and a copy should remain in the medical record. 

Use of these forms is optional but documentation is mandatory. Compliance with documentation requirements will ensure providers in facilities, especially nursing homes, meet legal requirements and prevent deficiencies with the NYSDOH survey process.

MOLST Chart Documentation Forms (align with NYSDOH Checklists)

  1.  MOLST Chart Documentation Form (Checklist 1 - adult with capacity any setting) 
  2.  MOLST Chart Documentation Form (Checklist 2 - adult with health care proxy any setting) 
  3.  MOLST Chart Documentation Form (Checklist 3 - adult with FHCDA surrogate) 
  4.  MOLST Chart Documentation Form (Checklist 4 - adult without FHCDA surrogate) 
  5.  MOLST Chart Documentation Form (Checklist 5 - adult without capacity in the community)  

For education, training and use of the new MOLST form (DOH-5003) please use the MOLST Instructions and Legal Requirements.   Checklists for Adult Patients above and the PowerPoint and recorded Webinar below. 

Hospital Sample Documentation Form(s)
(When surrogate makes decisions under FHCDA)


REMINDER:  Please remember the 2008 Supplemental MOLST forms (B-1621 and B-1622) are obsolete, given the changes in New York State (NYS) Public Health Law (PHL).  Eliminating Supplemental Forms is an effort to make the process more user-friendly.


  •  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.

Key Resources

For more information on MOLST, view MOLST for Professionals and NYSDOH and MOLST.

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