Nevada POLST Form: Step-by-Step

The Nevada POLST is a program consisting of the POLST form and a program to assure its effective implementation and provide continuing quality improvement. Towards these ends, it is vital that the POLST form is understood and completed as intended. The links below will explain each section of the POLST and points to keep in mind as you complete a POLST with a patient. In addition, you may download POLST Provider FAQ which may answer many questions including legal concerns.

Side 1 – Medical Orders should be completed with the patient and/or their representative (Agent as designated in an Advance Directive, Parent of a minor, or Guardian) and the patient’s physician. Other knowledgeable medical personnel (nurse practitioner, physician’s assistant, social worker or health educator) may complete Side 1 with the patient, but the patient’s physician must review the form with the patient, then the physician and patient or their representative must sign and date it at the bottom of Side 1 (Section C) and on Side 2 (Section F), respectively.

Side 1 – Medical Orders: Limited Medical Interventions
Instructions and Patient Information
POLST Section A: Cardiopulmonary Resuscitation (CPR)
• POLST Section B: Medical Interventions

Section C: Signature

Side 2 – Patient Preferences consists of collecting information from the patient’s existing documents and transferring it to the POLST form to assure this information is readily available as needed. Side 2 also documents who was involved in the POLST form completion process.

Side 2 – Patient Preferences
Section D: Organ Donation
Section E: Advance Directive
Section F: Signatures
Section G: Registry

Once Form is Completed