Can a CPR form be signed electronically?

Yes. Electronic signatures are legally recognized under the ESIGN Act (15 U.S.C. ch. 96, 2000) and by UETA in most states, provided intent, consent, attribution, and record retention requirements are met.

What HIPAA obligations apply to the form?

Healthcare CPR Forms contain protected health information and must be secured; retain safeguards and retention practices consistent with HIPAA and 45 CFR §164.530(j).

Who may sign for the patient?

The patient may sign when capable; an authorized surrogate or legally appointed decision‑maker signs where state law permits and documentation exists.

Are witnesses or notarization always required?

Not always. Witness and notary rules vary by state and by the type of directive; check state law and institutional policy before finalizing execution procedures.

How do I update or revoke a CPR form?

Document a new, dated form that supersedes prior instructions; notify care teams and update the EHR. For revocation rules, follow state law and facility policy.

Is remote online notarization allowed?

RON availability depends on state law and notary rules; where permitted, use compliant identity proofing, audio‑video recording, and retention controls.

Healthcare CPR Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE CPR FORM

Patient Information

Patient Name: Date of Birth: Gender:

Address Phone

Emergency Contact

Name Phone Relationship

Insurance Information

Insurer / Provider Policy Number Group Number Subscriber Name

Medical History

Current Medications Allergies Prior Surgeries or Hospitalizations Chronic Medical Conditions

CPR Preference

Explanation: Cardiopulmonary resuscitation (CPR) is an emergency procedure performed when a patient's heart and/or breathing stops. CPR may include chest compressions, rescue breaths, electrical shock (defibrillation), airway management, and medications. While CPR can restore circulation and breathing in some cases, it may be unsuccessful and may cause injuries such as rib fractures, organ damage, or prolonged dependence on life-sustaining treatments.

Select the patient's resuscitation preference (only one option should be chosen):

Full Code — Attempt all indicated resuscitative measures, including CPR, defibrillation, airway management, and advanced life support.

Do Not Resuscitate (DNR) / No CPR — Do not perform chest compressions, defibrillation, or advanced airway management if the heart or breathing stops. Comfort measures and other indicated medical treatment may continue.

Allow Natural Death (AND) — Focus on comfort-focused measures and avoid invasive resuscitation; similar in effect to DNR with emphasis on palliative approach.

Additional directions or limitations regarding resuscitation

Discussion and Counseling

I acknowledge that a qualified clinician discussed the nature, expected outcomes, benefits, burdens, and reasonably foreseeable risks of CPR and alternatives with me. I had the opportunity to ask questions and to receive answers in terms I can understand.

Clinician Name Clinician Title / Role Date of Discussion Summary of Counseling / Patient Questions and Responses

I acknowledge that I received an explanation of CPR and associated outcomes and had the opportunity to ask questions.

HIPAA / Privacy Acknowledgment

I acknowledge that information related to my resuscitation preference will be documented in my medical record and may be communicated to members of my care team as necessary to honor my wishes. This information is protected under privacy laws and will be used and disclosed in accordance with applicable privacy and confidentiality rules.

I acknowledge the privacy statement above.

Authorization and Validity

This CPR preference becomes part of the medical record and is effective as of the Effective Date below. The patient or authorized representative may revoke or change this preference at any time by notifying the care team. Changes will be documented in the medical record.

Effective Date Authorization Expiration Date (if applicable)

Certifications and Notices

By signing below, I certify that I have had an opportunity to discuss my resuscitation preferences with a qualified clinician, that the discussion included the risks, benefits and alternatives to CPR, and that I understand the likely outcomes of my selection. I understand that refusing CPR may result in death. I further understand that I may revoke or modify this instruction at any time while I retain decision-making capacity.

Patient Printed Name:

Signature:

Date:

Relationship to Patient (if not patient):

What the Healthcare CPR Form Is and when it's used

The Healthcare CPR Form records a patient’s cardiopulmonary resuscitation preferences and code status, typically indicating Full Code, Do Not Resuscitate (DNR), or limited interventions. Clinical teams use it during admission, transfer, or emergent care to guide immediate decisions and to document informed consent or refusal. Completed forms become part of the medical record and must be handled under applicable privacy and retention rules. Electronic execution is recognized under U.S. e‑signature law when consent and reproducibility requirements are met.

Why a clear Healthcare CPR Form matters for patient care

A properly completed Healthcare CPR Form reduces clinical uncertainty, documents informed choice, and creates a durable record that supports rapid, appropriate responses in emergencies while aligning with privacy and legal standards.

Who typically completes and relies on this form

Clinicians, admitting teams, and authorized surrogates complete the Healthcare CPR Form during admission, transfer, or care‑planning conversations to record code status and consent.

Attending physicians — enter medical orders and clinical justification for the chosen code status.
Nurses and admitting staff — capture patient preferences and file the completed form in the chart.
Patients and authorized surrogates — confirm understanding, provide informed consent or refusal, and sign where required.

Keep the completed form accessible in the patient record and share it with on‑call teams and authorized representatives as needed.

Essential sections every professional Healthcare CPR Form should include

A professional form balances clarity for clinicians with legal sufficiency. Include patient identity, explicit code‑status choices, clinical rationale, and traceable signature metadata so teams can act confidently and auditors can verify the record.

Patient Header

Clear patient identifiers, date/time, and facility to ensure the form attaches to the correct medical record.

Identification

Full legal name, date of birth, and medical record number to prevent mismatches across systems.

Code Status

Explicit selectable options (Full Code, DNR, Partial/Specified Interventions) with space for clinician notes.

Clinical Rationale

Short statement of clinical indication, prognosis, or advance directive reference to support decisions.

Signatures

Signer name, role, signature, date/time, and witness or notary fields where state law requires them.

Metadata

Audit trail entries (timestamp, IP, device), versioning, and EHR link for legal reproducibility.

Step-by-step: completing the Healthcare CPR Form

Follow these steps in order to ensure the form is valid, accessible, and actionable at the bedside or in transport.

01

Verify identity: Confirm name and DOB match the chart before documenting code status.
02

Discuss options: Explain interventions, outcomes, and alternatives to the patient or surrogate.
03

Record decision: Select the precise code‑status option and add concise clinical notes.
04

Sign and file: Collect required signatures, date the form, and upload to the EHR immediately.

Configuring a digital workflow for the Healthcare CPR Form

When converting the form to a digital workflow, keep authentication, conditional fields, and EHR routing consistent with clinical needs and legal requirements.

Field	Configuration
eSignature method	Email link or RON where permitted
Authentication	Email + SMS code or ID proofing for higher assurance
Conditional fields	Show witness/notary when state law requires
EHR integration	Automate upload via FHIR or secure API

Technical considerations for digital signing and storage

Select tools that support secure PDF formats, audit trails, and HIPAA‑grade controls when eSigning Healthcare CPR Forms.

EHR Integration: FHIR/HL7 support for direct charting
Document formats: PDF and DOCX accepted for upload
Authentication: Email, SMS, or stronger credentialing

Ensure vendor compliance with HIPAA and ESIGN/UETA requirements and verify retention and access controls before enabling production workflows.

Where to send and how to route completed forms

Routing rules ensure care teams can find and act on the CPR form immediately; store signed copies in the official record and notify responsible clinicians.

EHR upload: Attach a signed PDF to the patient chart using FHIR or document import.
Patient chart: Place a visible code‑status banner in admitting notes and nursing flowsheets.
Care team: Notify primary team, on‑call physicians, and nursing staff after signing.
External share: Provide copies to authorized surrogates or receiving facilities on transfer.

Timing: when the Healthcare CPR Form must be completed or reviewed

Timely completion and periodic review help ensure decisions reflect current wishes and clinical conditions.

On admission:

Complete or verify code status at initial admission intake.

After clinical change:

Update whenever prognosis or treatment goals change substantially.

Before procedures:

Confirm status before anesthesia or high‑risk interventions.

Annual review:

Review advance directives and CPR preferences at least yearly or per policy.

On transfer:

Send signed form with the patient to receiving facility or EMS.

Required data elements to make the form valid

Patient Name: Full legal name

Date of Birth: MM/DD/YYYY

Medical Record Number: Facility MRN

Code Status: Full Code or DNR

Signature: Signer name and date

Witness/Notary: If state requires

Legal and clinical risks of an incomplete or incorrect form

Delayed care: Potential for inappropriate or withheld interventions

HIPAA breach: Unauthorized disclosure risk and regulatory fines

Invalid directive: Form may be unenforceable if improperly executed

Civil liability: Malpractice or negligence claims may follow

Criminal exposure: Rare cases of criminal liability for willful misuse

Billing errors: Incorrect codes or claims from mismatched documentation

Common mistakes to avoid when preparing the form

Leaving dates or times blank which can create ambiguity during urgent decisions and impede legal validity.
Entering nonstandard or vague code‑status language instead of choosing predefined options clinicians understand.
Mismatched patient identifiers between the form and EHR that lead to misfiling or duplicate records.
Failing to collect required witness or notary attestations where state law imposes them.

Practical tips for accurate and efficient completion

Adopt consistent templates, verify identity, and automate routing to reduce errors and increase accessibility across care teams.

Use standard options

Prefer predefined code‑status checkboxes over free text to reduce confusion.

Immediate upload

Save a signed PDF to the EHR within minutes of signing.

Audit metadata

Keep timestamps, signer attribution, and device/IP records for reproducibility.

Train staff

Regularly train admitting and clinical staff on workflows and legal requirements.

Real-world scenarios showing how the form is used

Two typical scenarios illustrate why clarity and traceability on the Healthcare CPR Form are important in different care settings.

Hospital admission

A patient with advanced COPD is admitted after respiratory failure

Clinician documents DNR after informed discussion
The signed form is uploaded to the EHR and flagged for all covering providers to view during subsequent shifts.

Nursing home transfer

An elderly resident is transferred to acute care following sudden decline

Family confirms existing limited‑intervention preference
The transferring nurse provides a printed signed copy and the receiving team files it in the admitting notes.

eSignature vendor comparison for Healthcare CPR Forms

Compare basic plan economics and compliance features when choosing an eSignature provider to process Healthcare CPR Forms in a HIPAA context.

	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 free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (premium)	Varies	Varies	Varies	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No envelope cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions about the Healthcare CPR Form

Answers to common legal, clinical, and technical questions about completing, signing, and storing Healthcare CPR Forms.

Need help? Contact support

Can a CPR form be signed electronically?
Yes. Electronic signatures are legally recognized under the ESIGN Act (15 U.S.C. ch. 96, 2000) and by UETA in most states, provided intent, consent, attribution, and record retention requirements are met.
What HIPAA obligations apply to the form?
Healthcare CPR Forms contain protected health information and must be secured; retain safeguards and retention practices consistent with HIPAA and 45 CFR §164.530(j).
Who may sign for the patient?
The patient may sign when capable; an authorized surrogate or legally appointed decision‑maker signs where state law permits and documentation exists.
Are witnesses or notarization always required?
Not always. Witness and notary rules vary by state and by the type of directive; check state law and institutional policy before finalizing execution procedures.
How do I update or revoke a CPR form?
Document a new, dated form that supersedes prior instructions; notify care teams and update the EHR. For revocation rules, follow state law and facility policy.
Is remote online notarization allowed?
RON availability depends on state law and notary rules; where permitted, use compliant identity proofing, audio‑video recording, and retention controls.

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