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.

Side 1 – Medical Orders should be completed with the patient and/or (if they lack decisional capacity) their representative (Agent, aka DPOA-HC, as designated in an Advance Directive, parent of a minor, or Guardian) or surrogate and the patient’s physician, APRN or PA. Other knowledgeable medical personnel (social worker or health educator) may complete Side 1 with the patient, but the patient’s physician, APRN or PA must review the form with the patient, then the physician, APRN or PA and patient or their representative/surrogate must sign and date it at the bottom of Side 1 (Section E).

Side 1 – Medical Orders: Limited Medical Interventions

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.

What to do once the POLST form is completed – The POLST form should be kept with the patient whenever possible. If in a facility where HIPAA restricts availability of the POLST form, to conform to legal requirements to honor a POLST medical order, protocols and procedures shall be implemented to assure the POLST form is available when needed. Otherwise, the patient should be instructed to keep their POLST next to their bed or on their refrigerator where EMS is instructed to look.

A copy of the POLST should always be retained in the patient’s medical record.

The POLST should be regularly reviewed to assure it reflects the patient’s current health status and preferences.