Do Not Resuscitate Order (DNR) Template
This Do Not Resuscitate Order is intended to comply with the laws of [State Name]. Please ensure all sections are filled out correctly to reflect your wishes regarding resuscitation.
Patient Information
- Patient's Full Name: ___________________________
- Date of Birth: ___________________________
- Medical Record Number: ___________________________
- Address: ___________________________
Physician Information
- Physician's Full Name: ___________________________
- Medical License Number: ___________________________
- Contact Information: ___________________________
Patient's Wishes
The patient hereby declares that in the event of cardiac or respiratory arrest, the following wishes apply:
- Do Not Resuscitate (DNR) Order is in effect.
- Please provide comfort measures as needed.
- Other specific wishes: ___________________________
Signatures
By signing below, the patient or their authorized representative confirms understanding of this Do Not Resuscitate Order and its implications:
- Patient or Authorized Representative's Signature: ___________________________
- Date: ___________________________
- Witness Signature: ___________________________
- Date: ___________________________
This DNR Order should be reviewed regularly, particularly when there is a change in the patient's condition or treatment preferences.