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Valid Do Not Resuscitate Order Template

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Do Not Resuscitate Order (DNR) Template

This Do Not Resuscitate Order (DNR) is created in accordance with the laws of [State Name]. The purpose of this document is to communicate preferences regarding resuscitation in the event of a medical emergency.

Patient Information:

  • Patient Name: ________________
  • Patient Date of Birth: ________________
  • Patient Address: ________________

Medical Condition(s):

  • Primary Diagnosis: ________________
  • Secondary Diagnosis: ________________

Physician's Information:

  • Physician Name: ________________
  • Physician Contact Number: ________________

Instructions: By signing this document, I request that resuscitation measures not be initiated for the patient named above. This decision is made based on the understanding of the patient's current medical condition and personal values.

Authorized Signatures:

  1. Patient Signature: ___________________________ Date: __________
  2. Guardian/Power of Attorney Signature: ___________________________ Date: __________
  3. Physician Signature: ___________________________ Date: __________

This document should be kept in a prominent place and copies should be provided to family members, caregivers, and any healthcare providers involved in the patient's care.

For more information, please consult with a legal professional or a healthcare provider regarding the specific laws and regulations related to DNR orders in [State Name].

State-specific Information for Do Not Resuscitate Order Forms

Form Data

Fact Name Description
Definition A Do Not Resuscitate (DNR) order is a legal document that instructs medical personnel not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac arrest.
Legal Standing DNR orders are recognized under state law, and each state has specific regulations governing their use. For example, in California, the DNR is governed by the California Health and Safety Code.
Patient Autonomy DNR orders reflect a patient's wishes regarding end-of-life care, emphasizing the importance of patient autonomy in medical decision-making.
Documentation Requirements Most states require that a DNR order be documented in writing and signed by the patient or their authorized representative, along with a physician's signature.
Emergency Medical Services (EMS) Protocols Emergency medical services must be trained to recognize and honor DNR orders. In many states, EMS personnel are legally obligated to follow these orders during emergencies.

Do Not Resuscitate Order - Usage Guidelines

Completing a Do Not Resuscitate Order (DNR) form is an important step in expressing your medical wishes. Once filled out, the form should be shared with your healthcare provider and kept in an easily accessible location. This ensures that your preferences are respected in a medical emergency.

  1. Obtain the DNR form from your healthcare provider or state health department.
  2. Fill in your full name and date of birth at the top of the form.
  3. Provide the name of your primary healthcare provider.
  4. Indicate your current medical condition or diagnosis, if applicable.
  5. Review the instructions on the form carefully to ensure you understand the implications.
  6. Sign and date the form. This is crucial for its validity.
  7. If required, have a witness sign the form, ensuring they meet any state-specific requirements.
  8. Make copies of the completed form for your records and to share with your healthcare provider.
  9. Store the original form in a place where it can be easily accessed in an emergency.

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Dos and Don'ts

When filling out the Do Not Resuscitate Order form, it is essential to approach the process with care. Here are some important guidelines to follow:

  • Do ensure you understand the implications of a Do Not Resuscitate Order. It is a significant decision regarding your medical care.
  • Do discuss your wishes with your healthcare provider and family members. Open communication can help ensure everyone is on the same page.
  • Do complete the form accurately and provide all required information. Incomplete forms may not be honored in an emergency.
  • Do keep copies of the completed form in accessible locations, such as with your medical records or at home.
  • Don't rush the process. Take your time to consider your options and make informed decisions.
  • Don't fill out the form under pressure from others. Your wishes should be respected and prioritized.
  • Don't assume that verbal agreements are sufficient. Written documentation is necessary to ensure your wishes are followed.
  • Don't forget to review the form periodically, especially if your health status or preferences change.

Common mistakes

  1. Not Understanding the Purpose: Many individuals fail to fully grasp the intent behind a Do Not Resuscitate (DNR) Order. This document is meant to communicate a person's wishes regarding resuscitation in the event of cardiac or respiratory arrest. Without a clear understanding, people might fill out the form without considering its implications.

  2. Inaccurate Personal Information: Providing incorrect personal details can lead to confusion during a medical emergency. It's crucial to ensure that the name, date of birth, and other identifying information are accurate and up to date.

  3. Failure to Discuss with Healthcare Providers: Some individuals fill out the DNR form without consulting their doctors. Engaging in a conversation with healthcare professionals can clarify the medical aspects and consequences of a DNR order, ensuring that the decision aligns with one’s health condition and preferences.

  4. Not Informing Family Members: A common oversight is neglecting to inform family members about the DNR order. This can lead to confusion and conflict during critical moments. Family discussions can help ensure that everyone understands the individual's wishes.

  5. Not Signing or Dating the Form: A DNR order must be signed and dated to be valid. Some people forget this critical step, rendering the document ineffective. Always double-check that all required signatures are present.

  6. Using Outdated Forms: Healthcare facilities may have specific requirements for DNR orders that can change over time. Using an outdated form may not meet current legal standards or hospital policies, which can invalidate the order.

  7. Ignoring State-Specific Regulations: Each state has its own laws regarding DNR orders. Failing to adhere to these regulations can result in complications. It’s essential to be aware of and follow the specific guidelines that apply in your state.

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