Can a DNR be signed electronically?

Yes. Electronic signatures that demonstrate signer intent, consent to electronic records, attribution, and durable record retention are generally valid under federal and state e-signature laws. Confirm your facility’s policy and ensure HIPAA protections for protected health information.

Who can sign if the patient lacks capacity?

A legally authorized representative or surrogate identified by state law or existing advance directive may sign. Document the authority source and any required supporting documentation to reduce dispute risk.

Does a witness or notary make the form stronger?

Witnesses or notarization can strengthen enforceability in some jurisdictions and are sometimes required by facility policy; follow state rules and institutional protocols for witnessing or notarizing medical orders.

How should conflicts with advance directives be handled?

When a DNR conflicts with an advance directive, clinicians should reconcile documents, document patient or surrogate intent, and consult legal or ethics resources; institutional policy should guide which document controls in your setting.

What if EMS encounters a patient without a visible DNR?

EMS personnel generally follow local protocols; absence of a documented, accessible DNR means life-sustaining measures will typically be provided. Encourage patients to carry visible documentation or register orders where EMS can access them.

How do I update or revoke a DNR?

Document revocations or replacements in the medical record with signature and date. If a patient revokes in person, note the clinical encounter; if revoked remotely, follow facility procedures for confirming identity and consent before changing the order.

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Do Not Resuscitate Order Form

Do Not Resuscitate Order Form

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USLegal Pamphlet on Do Not Intubate

USLEGAL

USLEGALFORMS.COM

INTRODUCTION

Do Not Intubate (DNI) means that no breathing tube will be placed in the throat in the event of breathing difficulty or respiratory arrest. Neither an endotracheal tube nor an esophageal obturator airway will be inserted to secure the airway or to assist ventilation. Intubation might prevent a heart attack or respiratory arrest.

Refusal of intubation does not mean refusal of other techniques of resuscitation. If you do not want mechanical ventilation (breathing), you must discuss intubation because it may be included as part of a DNI order. Even if you have completed a DNR order that does not mean that you have refused to be intubated. DNR applies to patient who experience acute cardiopulmonary arrest, where as DNI applies only to intubation for patients who experience impending pulmonary failure. Patients may not want CPR and have a DNR order, but may benefit from ventilator support and therefore may not wish to have a DNI order. Refusal of intubation does not mean refusal of other techniques of resuscitation. Since intubation is required after successful cardiopulmonary resuscitation (CPR), the presumption in the case of full cardiopulmonary arrest is that the patient agrees to intubation and mechanical ventilation.

Patients may not want CPR and have a DNR order, but may benefit from ventilator support and therefore may not wish to have a DNI order. Rather, they may wish to have a limited trial or long-term intubation and mechanical ventilation. A time-limited trial of intubation and mechanical ventilation provides the patient a choice of a trial of therapy where the underlying acute impending pulmonary failure is potentially reversible and the patient does not wish long-term mechanical ventilation.

However, the discussion regarding a Do Not Intubate order is in the context of a patient/resident who still has a pulse and/or is breathing. Such a patient who chooses not to be resuscitated may still consent to external defibrillation, Heimlich maneuver, clearing of the airway, etc. If you do not want mechanical ventilation (breathing), you must discuss intubation because it may be included as part of a DNR order. Even if you have completed a DNR order that does not mean that you have refused to be intubated. If you do not want life mechanically sustained, you must discuss your decision about intubation with your doctor.

ENFORCING A DNI ORDER

The DNI order is generally prominently noted in the patient's medical chart. The patient can change a DNI order at any time, and experts urge that such an order be reviewed regularly. In a DNI situation, a patient is provided comfort care. Without such an order, emergency medical technicians are legally required to perform CPR. It is also essential to keep a DNI Order visible and accessible at all times so that emergency medical personnel, such as EMTs and paramedics, can provide care and transport without intubation. Some families keep the document on the refrigerator door or in a clearly marked folder.

What the Do Not Resuscitate Order Form Is

A Do Not Resuscitate Order Form (DNR) is a clinical and legal instruction documenting a patient’s preference to decline cardiopulmonary resuscitation (CPR) and advanced cardiac life support in the event of cardiac or respiratory arrest. The form is typically completed by a treating clinician, signed by the patient or an authorized surrogate, and entered into the medical record. It records patient identity, the specific treatment limitations, the clinician’s order, effective date, and any witness or notarization required by the treating facility or state law. The form must be clear, current, and accessible to emergency responders and care teams.

Why a Clear DNR Order Matters

A properly completed Do Not Resuscitate Order Form makes patient wishes actionable at the point of care, reduces confusion among clinicians and emergency responders, and helps align treatment with goals of care while documenting medical decision-making and consent under applicable electronic signature and medical-record rules.

Who Completes and Relies on DNR Orders

Typical users include clinicians who issue the order, patients or their legally authorized representatives who consent, and downstream care teams who must follow the instruction.

Physicians and advanced practice clinicians who evaluate prognosis and enter the medical order into the chart.
Patients or surrogate decision-makers who confirm preferences and provide informed consent.
Emergency medical services, nursing staff, and long-term care personnel who implement the order in an emergency.

Who Signs and Authorizes a DNR

Patient

The adult patient signs when they have capacity to express informed refusal of resuscitative measures; the signature documents consent and intent and informs clinicians and emergency responders of treatment limits.

Authorized Surrogate

When the patient lacks capacity, a legally authorized representative or durable power of attorney for healthcare may sign consistent with state law and existing advance directives to legally bind the order.

Essential Elements of a Professional DNR Order

A complete Do Not Resuscitate Order Form combines clinical order language with identifying data, signatory authority, and distribution metadata so that the instruction is unambiguous and enforceable at the bedside or in transit.

Patient Identification

Full legal name, date of birth, medical record number, and contact details to ensure the order applies to the correct individual and integrates with the patient’s chart.

Clinical Order Text

Clear physician or authorized clinician statement that CPR and related interventions are withheld, describing the scope and any exceptions to avoid ambiguity in an emergency.

Signer Information

Printed name, relationship to patient (if applicable), and role (patient, surrogate, clinician) so signatory authority is documented and verifiable.

Dates and Effective Time

Order effective date and time plus any expiration or review date to make validity and timing explicit for care teams and EMS.

Authentication

Clinician signature, credentials, and license number; facility stamp or electronic audit trail to show who issued and authorized the order.

Witness/Notary

Space for witness signatures or notarization where required by state or facility policy to meet local legal or institutional requirements.

Security and Compliance Considerations

Encryption: AES-256 at rest; TLS 1.2/1.3 in transit

HIPAA BAA: Business Associate Agreement required for PHI

Audit Trail: Timestamped logs of signing events

Access Controls: Role-based permissions for view/edit

Authentication: Multi-factor or equivalent signer verification

Retention Policy: Controlled records retention and deletion

Risks When a DNR Form Is Incorrect

Invalid Signatory: Order may be unenforceable

Missing Information: Ambiguity in treatment limits

Outdated Order: Order may not reflect current wishes

Unauthorized Revocation: Conflicting directives create legal exposure

Improper Storage: EMS or staff may not locate order

HIPAA Violations: Improper sharing can trigger compliance risk

Common Preparation Pitfalls

Failing to confirm patient capacity or surrogate authority before acceptance of the signature increases risk the order will be contested.
Using vague language such as 'do not initiate aggressive measures' rather than naming CPR and related interventions can cause inconsistent application.
Not distributing the signed order to EMS, ambulatory records, and visible location in the chart can delay adherence when seconds matter.
Neglecting to update or review the DNR after significant clinical changes may leave instructions that no longer match patient goals.

Step-by-Step: Completing the DNR Order Form

Follow this sequence to produce a clear, legally sound DNR order that can be acted on by clinical teams and emergency responders.

01

Confirm Identity: Verify the patient using government ID or medical record details.
02

Assess Capacity: Document clinical findings showing the patient can decide or identify authorized surrogate.
03

Enter Clinical Order: Clinician writes clear, dated order stating CPR is withheld.
04

Authenticate and Share: Obtain signature, witness/notary if required, then place in chart and provide copy to EMS.

How the DNR Order Reaches Care Teams

A typical distribution workflow ensures the DNR is visible to everyone involved in acute decisions, both inside and outside the facility.

Order Entry: Clinician places the DNR order in the electronic medical record or on the facility form.
Authentication: Patient or surrogate signs; clinician signs and dates the order to authorize it.
Record Flagging: Chart is flagged and a copy is stored in a prominent location for quick access.
External Notification: Provide EMS, outpatient providers, and transfer facilities with a copy where applicable.

Configuring an Electronic DNR Workflow

Key configuration items for an electronic DNR workflow focus on authentication, field placement, and routing to clinical and emergency teams.

Field	Configuration
Authentication Method	Email + SMS code or two-factor for clinician and patient as required
Signature Placement	Separate fields for patient/surrogate and clinician with date/time
Notification Routing	Auto-send copies to chart, EMS contact, and primary outpatient clinician
Storage Location	Write to EMR document library and mark active flag

Technical Requirements for eSubmission and Access

Ensure the chosen platform supports HIPAA-required protections and integrates with your EMR or document repository to minimize manual steps.

PDF and EMR Support: Exportable signed PDF and EMR-native document storage
Authentication Options: Email, SMS, SSO, or stronger signer verification as facility policy requires
Audit and Access Logs: Detailed logs showing signer identity, IP, and timestamps

Timing Considerations and Review Expectations

DNR orders should be dated and reviewed after major clinical changes; facilities often set internal review intervals to confirm continued applicability.

Immediate Effect:

Order takes effect when signed and entered in the medical record

Review After Major Change:

Reassess after significant clinical events or capacity changes

Transfer of Care:

Provide a copy at discharge, transfer, or on EMS handoff

Periodic Review:

Facilities commonly require periodic confirmation during care milestones

Expiration or Revocation:

Document revocation or replacement with date and signer details

Comparing eSignature Options for DNR Workflows

Platform selection for electronic DNR forms should weigh price, HIPAA readiness, audit trails, and bulk or automated distribution — signNow is listed first for comparison consistency.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Real-World Scenarios Where a DNR Order Is Used

These scenarios show common contexts in which a clear DNR Order Form changes care delivery and reduces downstream disputes.

Hospital Admission

An elderly patient with terminal illness declines resuscitation

Clinician documents bedside discussion and enters the DNR order
The order is uploaded to the EMR, visible on the chart cover sheet, and a copy is provided to discharge planners to inform follow-up care and hospice transition.

Nursing Home Transfer

A resident with progressive dementia has an advance directive naming a surrogate

The surrogate confirms the DNR and signs the facility order
Staff record the signed DNR in the resident’s chart and provide a wristband or visible flag so EMS and transfer facilities know the resident’s status.

Practical Tips for Accurate DNR Completion

Follow these best practices to minimize legal and clinical ambiguity while ensuring patient wishes are recorded and honored.

Use Standardized Language

Adopt your facility or state-approved form wording to avoid interpretive differences and to meet statutory requirements.

Confirm Signatory Authority

Verify whether the signer is the patient or an authorized surrogate and document the basis for surrogate authority in the chart.

Ensure Accessibility

Place the signed order in a prominent EMR location and provide copies to EMS, outpatient clinicians, and care partners when appropriate.

Document Revocations

Immediately document any revocation or replacement of the order with date, time, and signer to prevent conflicting instructions.

Frequently Asked Questions About DNR Orders

Answers to common operational and compliance questions help clinical and administrative staff complete and rely on DNR orders appropriately.

Need help? Contact support

Can a DNR be signed electronically?
Yes. Electronic signatures that demonstrate signer intent, consent to electronic records, attribution, and durable record retention are generally valid under federal and state e-signature laws. Confirm your facility’s policy and ensure HIPAA protections for protected health information.
Who can sign if the patient lacks capacity?
A legally authorized representative or surrogate identified by state law or existing advance directive may sign. Document the authority source and any required supporting documentation to reduce dispute risk.
Does a witness or notary make the form stronger?
Witnesses or notarization can strengthen enforceability in some jurisdictions and are sometimes required by facility policy; follow state rules and institutional protocols for witnessing or notarizing medical orders.
How should conflicts with advance directives be handled?
When a DNR conflicts with an advance directive, clinicians should reconcile documents, document patient or surrogate intent, and consult legal or ethics resources; institutional policy should guide which document controls in your setting.
What if EMS encounters a patient without a visible DNR?
EMS personnel generally follow local protocols; absence of a documented, accessible DNR means life-sustaining measures will typically be provided. Encourage patients to carry visible documentation or register orders where EMS can access them.
How do I update or revoke a DNR?
Document revocations or replacements in the medical record with signature and date. If a patient revokes in person, note the clinical encounter; if revoked remotely, follow facility procedures for confirming identity and consent before changing the order.

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