Nevada Do Not Resuscitate (DNR) Order FormNevada Do Not Resuscitate (DNR) Order Form
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NEVADA POLST (Physician Order for Life-Sustaining Treatment)
HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS & ELECTRONIC REGISTRY
Faxed, copied or electronic versions of a Nevada POLST are legal and valid

SIDE 1: Medical Orders
Consult this form when patient lacks decisional
capacity. It is intended to be honored by any healthcare provider who treats the patient in any health-care
setting, including, without limitation, a residence, health
care facility or the scene of a medical emergency (NRS
449.694.). A section not completed does not invalidate
the rest and indicates full treatment for that section.
Section

A

CPR
Check one only

Section

B
Interventions

Last Name/First/Middle Initial

Date of Birth (dd/mm/yr)

/

/

Last 4 SSN

Gender

___ ___ ___ ___

M
F

CARDIOPULMONARY RESUSCITATION (CPR). Patient/resident has no pulse & is not breathing.
Attempt Resuscitation (CPR)
Allow Natural Death (Do Not Attempt Resuscitation)
(See Section B: Full Treatment required)

If availab