Louisiana Do Not Resuscitate (DNR) Order FormLouisiana Do Not Resuscitate (DNR) Order Form
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HIPAA PERMITS DISCLOSURE OF LaPOST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY

LOUISIANA PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (LaPOST)
FIRST follow these orders, THEN contact physician. This
is a Physician Order Sheet based on the person’s medical
condition and wishes. Any Section not completed implies
full treatment for that section. Everyone shall be treated
with dignity and respect. Please see www.La-POST.org for
information regarding “what my cultural/religious heritage
tells me about end of life care.”

LAST NAME
_________________________________________________________________
FIRST NAME/MIDDLE INITIAL
_________________________________________________________________
DATE OF BIRTH
_________________________________________________________________

PATIENT’S DIAGNOSIS OF LIFE LIMITING DISEASE AND IRREVERSIBLE CONDITION:
________________________________________________________________________________________________________________________________________
_______________________