POLST - DNR Section
Section A: Cardiopulmonary Resuscitation (CPR)
Attempt Resuscitation/CPR (Full Code)
Do Not Attempt Resuscitation (DNR/no CPR)
Physician/Authorized Practitioner Signature
Signature:
Date:
Name (print):
Phone Number:
Patient or Surrogate Signature (optional but recommended)
Signature:
Date:
Name (print):
Relationship to Patient:
Review of this order is recommended periodically and whenever the patient's condition changes.