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Completing the 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 continuous 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.


Preparation: Be sure the patient is appropriate for POLST (you would not be surprised should this patient die within the next year) and that you are prepared for "The Conversation". Be sure to have printed out a Registration Agreement form for the Secretary of State's Nevada Lockbox in order to submit a copy of the POLST for ready and easy retrieval by all health care providers who may treat the 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 (nurse, social worker, health educator, chaplain) 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



Side 2 – Supplementary Information: 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.


  • Supplementary Information

  • Instructions - Many questions are answered on the back of the POLST form; please read these sections for additional instructions and information.


After Completion: The POLST form should be submitted to the Nevada Lockbox along with the Registration Agreement printed previously and completed with the POLST.


Keep the POLST form with the patient whenever possible.

  • In a facility where HIPAA restricts the general availability of the POLST form, in order to meet legal requirements to honor a POLST medical order; protocols, procedures, and triggers shall be implemented to assure the POLST form is available when needed.

  • At home or in another residential location, the patient should be instructed to keep their POLST next to their bed or on their refrigerator where EMS is trained to look.

  • A patient's POLST should always be presented to EMS when summoned.

  • 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.

Side 2 - Supplementary Information
After Completion
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