Printed on bright yellow paper, this portable medical order is for New Hampshire patients at risk of a life-threatening event because of a serious life-limiting condition or advanced frailty. Based on the national form, it records CPR, initial treatment, additional orders and medically assisted nutrition. Choosing No CPR makes it a DNR order under RSA 137-J:26 V(b), so no separate DNR is needed.
A physician, physician assistant or APRN completes the orders after a conversation with the patient or representative and signs Section F; the patient or representative signs Section E. A social worker, nurse or clergy member who helped is listed on page 2.
Download the current version from the source each time; forms change without notice.
New Hampshire POLST - Medical Order
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Yes, when No CPR is chosen. Section A states that this will constitute a DNR order and no separate DNR order will be required, citing RSA 137-J:26 V(b). Without that statement, a POLST is not a substitute for the pink Portable DNR, and a DNR bracelet or necklace requires a valid DNR order.
A physician, physician assistant or advanced practice registered nurse. Forms are invalid if not reviewed and signed by a provider, and only providers authorized to sign POLST forms in New Hampshire may sign. Verbal orders are acceptable with a follow-up signature, and electronic signatures are valid.