Please consult an attorney or health provider from your state for a DNR that meets all of your state’s requirements.
Last reviewed: 10/02/2023
Using this Document
A Do Not Resuscitate (DNR) order is a medical directive that specifies a patient’s wish to not receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. A DNR order is typically documented in a patient’s medical record and may not directly involve HIPAA compliance since it’s a medical treatment decision rather than a disclosure of medical information. However, the decision to have a DNR order should be based on informed consent and a discussion with a healthcare provider.
Please note that the requirements and forms for DNR orders may vary by state and healthcare facility. It is essential to consult with a healthcare provider and follow the specific guidelines and regulations in your jurisdiction to ensure that the DNR order is valid and legally compliant. Additionally, discussions about DNR orders should be documented in the patient’s medical record to ensure clarity and compliance with the patient’s wishes.
Here’s a template for a DNR order that emphasizes the need for proper discussion and documentation:
Do Not Resuscitate (DNR) Order
Patient Information:
- Full Name: ________________________________
- Date of Birth: ________________________________
- Address: ________________________________
- City: ________________________________
- State: ________________________________
- Zip Code: ________________________________
- Phone Number: ________________________________
Medical Provider Information:
- Name of Primary Physician: ________________________________
- Name of Healthcare Facility: ________________________________
- Address: ________________________________
- City: ________________________________
- State: ________________________________
- Zip Code: ________________________________
- Phone Number: ________________________________
Discussion and Decision: I, [Patient’s Full Name], have had a thorough discussion with my healthcare provider, [Primary Physician’s Name], regarding the risks, benefits, and alternatives of cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. I understand the implications and potential outcomes of receiving or not receiving CPR.
Based on this discussion and my informed consent, I hereby make the following healthcare decision:
- I request that all appropriate measures, including CPR, be taken to resuscitate me in the event of cardiac or respiratory arrest.
- I do not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. I understand that this decision may result in a natural death.
Signature: I have made this DNR decision willingly and with a full understanding of its implications on this [Date].
Patient’s Signature: ________________________________
Witnesses (if required by state law):
- Name: ________________________________ Signature: ________________________________ Date: ________________________________
- Name: ________________________________ Signature: ________________________________ Date: ________________________________
Healthcare Provider’s Note: I, [Primary Physician’s Name], have discussed the DNR decision with the patient, [Patient’s Full Name], and have provided appropriate medical guidance. The decision has been documented in the patient’s medical record.
Primary Physician’s Signature: ________________________________ Date: ________________________________