C.R.S. § 15-18.7-103: Medical orders for scope of treatment forms - form contents.

(1) A medical orders for scope of treatment form must include the following information concerning the adult whose medical treatment is the subject of the medical orders for scope of treatment form:

(a) The adult's name, date of birth, and sex;

(b) The adult's eye and hair color;

(c) The adult's race or ethnic background;

(d) If applicable, the name of the hospice program in which the adult is enrolled;

(e) The name, address, and telephone number of the adult's physician, advanced practice registered nurse, or physician assistant;

(f) The adult's signature or mark or, if applicable, the signature of the adult's authorized surrogate decision-maker;

(g) The date upon which the medical orders for scope of treatment form was signed;

(h) The adult's instructions concerning:

(I) The administration of CPR;

(II) Other medical interventions, including but not limited to consent to comfort measures only, transfer to a hospital, limited intervention, or full treatment; and

(III) Other treatment options;

(i) The signature of the adult's physician, advanced practice registered nurse, or physician assistant.