Can this form be signed electronically?

Yes. Electronic signatures are valid in the U.S. under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met; however, state exceptions for certain documents may apply.

Are electronic signatures accepted for healthcare orders?

Often yes, but consumer-facing healthcare records may require an ESIGN consumer disclosure and documented consent per 15 U.S.C. §7001(c). HIPAA-covered entities must use vendors that support a BAA and secure PHI during electronic processing.

What witness or notary steps are required?

Requirements vary by state; some jurisdictions require one or two witnesses, others require notary or physician signature for medical orders. Verify applicable state statutes and institutional policies; use RON only where state law permits remote notarization and retention obligations are satisfied.

How should the signed form be stored?

Store signed forms in the patient's EMR as a tamper-evident PDF, maintain an audit trail, and enforce role-based access. Retain records per HIPAA (45 CFR §164.530(j)) and applicable state retention laws; keep originals accessible during care transitions.

Can EMS rely on this form in the field?

EMS reliance depends on state protocols and form compliance with jurisdictional requirements; some states require a physician-signed or state-issued DNR for EMS to withhold resuscitation. Provide portable, clearly labeled copies and notify EMS during transfers.

How do I revoke or change the order?

A competent patient can revoke or amend the DNH/DNI/DNR order by signing a new form, providing written revocation, or communicating with the care team per state law. Document revocations in the EMR and notify all involved providers immediately.

Electronic Signature
Templates
Healthcare
Healthcare DNH.DNI.DNR Form

Healthcare DNH.DNI.DNR Form

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

Healthcare DNH.DNI.DNR Form

Patient Information

Patient Full Legal Name Date of Birth Gender Address Primary Phone Emergency Contact (Name, Relationship, Phone)

Insurance Information

Insurance Provider Policy Number Group Number Subscriber Name (if different)

Medical History (Relevant)

Current Medications Allergies (including drug allergies) Prior Surgeries / Significant Procedures Chronic Conditions / Diagnoses

Directive Selection (Check all that apply)

Do Not Hospitalize (DNH)
I direct that, except for comfort care and outpatient therapies intended to maintain comfort at the current location, I am not to be transferred to a hospital for evaluation or treatment unless life-saving stabilization is possible and consistent with my other directives.

Do Not Intubate (DNI)
I refuse endotracheal intubation for mechanical ventilation. Non-invasive ventilation (e.g., CPAP/BiPAP) may be considered only if consistent with my stated goals of care.

Do Not Resuscitate (DNR)
I refuse cardiopulmonary resuscitation (CPR) including chest compressions, defibrillation, cardioversion, and emergency cardiopulmonary measures if my heart stops or if I stop breathing.

Scope and Limitations

These directions are intended to guide health care professionals in the event I have a life-threatening condition and cannot communicate my wishes. They apply to pre-hospital emergency responders, nursing staff, physicians, and allied health professionals unless superseded by a court-appointed healthcare decision-maker or an applicable statute.

If I have selected DNH, DNI, or DNR above, withhold the indicated interventions while providing care to maintain comfort, pain control, and dignity. This document does not require withdrawal of other necessary treatments unrelated to cardiopulmonary resuscitation, intubation, or hospitalization decisions unless explicitly stated below.

Additional Specific Treatments to Withhold or Allow (specify)

Patient Understanding and Certification

I certify that I am the person named above or I am the duly authorized representative with authority to complete this form. I understand the nature and consequences of selecting Do Not Hospitalize, Do Not Intubate, and/or Do Not Resuscitate orders. I understand that by refusing certain life-sustaining treatments I may be hastening death in some circumstances.

I understand that I retain the right to revoke or modify these instructions at any time by informing my treating clinician, rescinding this form in writing, or by executing a new advance directive. These instructions shall remain in effect until revoked or replaced, or until the expiration date indicated below.

Authorization Expiration Date (if any)

HIPAA and Information Release Acknowledgment

I acknowledge that my medical information related to the assessment and implementation of these directives may be shared among treating providers as necessary to carry out my treatment preferences. I authorize release of relevant medical information to effectuate these orders.

I acknowledge and consent to the limited release of medical information as described above.

Witness and Clinical Information

Witnesses are recommended to confirm the identity and mental capacity of the patient at the time this form was completed. The following information documents witness contacts and treating clinician information; these fields do not replace any required institutional witnessing or clinician signature policy.

Witness 1 Name Witness 1 Contact Witness 2 Name Witness 2 Contact Primary Treating Physician / Clinician Physician Contact / Facility

Capacity, Representative, and Revocation

By signing below I confirm that I have the capacity to make healthcare decisions at this time, unless I am signing as a legally authorized representative. If I become incapacitated, this directive shall be followed by my healthcare team and any designated decision-maker within the limits of applicable law.

If signing as Authorized Representative - Name Relationship to Patient (if signing as guardian/representative)

Additional Instructions / Clinical Notes

Notice: This document is intended to express the patient’s preferences regarding hospitalization, intubation, and resuscitation. Health care professionals should document this form in the medical record and follow applicable institutional policy and statutory requirements for implementation. Completion of this form does not alter any required institutional witness or clinician order requirements.

Patient Printed Name:

By:

Date:

What the Healthcare DNH.DNI.DNR Form Is

The Healthcare DNH.DNI.DNR Form records a patient’s specific life-sustaining treatment preferences — commonly Do Not Hospitalize (DNH), Do Not Intubate (DNI), and Do Not Resuscitate (DNR). It documents directions for clinicians and emergency responders about withholding hospital transfer, mechanical ventilation, or cardiopulmonary resuscitation when clinically appropriate. The form can be completed by a competent patient or by an authorized surrogate under state law and should be integrated with advance directives and medical orders. Accurate completion ensures patient wishes are clear across care settings and reduces uncertainty during urgent clinical decisions.

Why Clear DNH/DNI/DNR Orders Matter

Use this Healthcare DNH.DNI.DNR Form to make treatment limits explicit, support clinical decision-making, and reduce conflicts among providers and families. Clear documentation helps ensure respect for patient autonomy, aligns care with goals, and streamlines communication during emergencies.

Who Typically Completes and Uses This Form

Primary users include patients, healthcare proxies, attending clinicians, and facility administrators responsible for documenting and honoring treatment limitations.

Hospitals and emergency departments — to guide on-scene and inpatient care consistent with patient directives.
Long-term care and hospice providers — to coordinate end-of-life planning and reduce unwanted interventions.
Surrogates and family members — use when patients lack capacity to express current treatment preferences.

Organizations should train staff on recognizing the form, linking it to the medical record, and applying state surrogate rules.

Stepwise Process to Complete and Record the Form

Follow these sequential steps to complete, sign, and record the Healthcare DNH.DNI.DNR Form correctly and promptly.

01

Prepare Document: Gather identification, prior advance directive, and current medical orders.
02

Complete Fields: Enter choices, qualifiers, dates, and contact details accurately.
03

Obtain Signatures: Patient or authorized surrogate signs; include witness/notary if required.
04

Record & Communicate: Upload to EMR, notify care team, and provide copy to patient.

Configuring an Electronic Signing Workflow

Configure an electronic workflow consistent with clinical policies, legal requirements, and audit needs and documentation.

Field	Configuration
Signature Type	Choose e-signature or PKI digital signature per legal and clinical needs.
Authentication	Use email link or SMS code; add two-factor for higher assurance.
Templates	Create reusable template with conditional fields for common orders.
Notifications	Notify signers and clinical team on completion via email or EMR.
Storage	Save signed PDF to EMR and secure cloud storage with audit trail.

How Electronic Submission and Clinical Activation Flow

Typical routing for electronic submission, clinician review, and clinical activation of DNH/DNI/DNR orders across settings.

Upload Form: Sender uploads completed form to platform or EMR.
Assign Signers: Designate patient, surrogate, clinician signers and set signing order.
Authenticate: Use email verification, SMS code, or stronger methods as required.
Finalize: Store signed PDF, update medical orders, and alert care team.

Technical and Security Considerations for eSubmission

Digital signature workflows should meet authentication, encryption, and audit-trail requirements while accommodating state notarization rules.

Formats: PDF and DOCX; preserve page layout and metadata.
Integrations: Connect to EMR, Google Workspace, Microsoft 365, Salesforce.
Security: TLS 1.2/1.3 in transit; AES-256 at rest.

Timing and Review Expectations

Key timing considerations for completing, recording, reviewing, and updating DNH/DNI/DNR orders across care settings promptly.

Initial Completion:

Complete during care plan or when treatment preferences change.

Effective Date:

Forms should include an effective date in MM/DD/YYYY.

Periodic Review:

Review whenever clinical status changes or at routine intervals.

EMR Update:

Upload signed form to electronic medical record immediately.

Transfer of Care:

Provide copy at transitions between facilities and to EMS.

Key Milestones from Initiation to Review

Milestones from order initiation through activation and periodic review of DNH/DNI/DNR instructions across care transitions.

01

Order Initiation

Document patient preferences, select applicable orders, record effective date.

02

Signature & Witness

Obtain patient or surrogate signature; secure witnesses or notary if required.

03

Clinical Entry

Enter orders into EMR and notify care teams for bedside application.

04

Review Cycle

Set periodic review and update orders when clinical goals change.

Common Pitfalls to Avoid

Using vague or conditional language on the form creates ambiguity for clinicians, increasing the risk of unintended interventions or delays in honoring patient wishes.
Failure to match the patient’s legal name or DOB to medical records can prevent legal recognition of the order and lead to administrative rejection.
Not securing required witness signatures or notary acknowledgment under state law may invalidate the form or complicate enforcement in hospital settings.
Storing the signed form outside the EMR or failing to notify receiving clinicians at transfers undermines document effectiveness during emergencies.

Legal and Clinical Risks of Incorrect Forms

Clinical Liability: Unclear orders increase malpractice risk.

Delayed Care: Ambiguity may cause treatment delays.

Legal Challenge: Improper execution invites probate or guardianship disputes.

Regulatory Violation: Failing to follow HIPAA or state rules risks sanctions.

EMS Noncompliance: EMS may follow default protocols if form is missing.

Invalidation: Missing witness/notary can render form invalid.

Security, Privacy, and Compliance Checklist

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

HIPAA: BAA required for PHI handling.

Audit Trail: Timestamps, IP, signer actions recorded.

Authentication: Email, SMS, KBA, or 2FA options.

Access Control: Role-based access and SSO available.

Record Integrity: Tamper-evident PDFs and version history.

eSignature Pricing and Capabilities Comparison

Baseline eSignature pricing and capabilities relevant to Healthcare DNH.DNI.DNR Form execution; signNow is listed first in the comparison.

	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 plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions and Practical Answers

Answers to frequent questions about completing, signing, and storing Healthcare DNH.DNI.DNR Forms, including electronic execution and state considerations.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are valid in the U.S. under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention requirements are met; however, state exceptions for certain documents may apply.
Are electronic signatures accepted for healthcare orders?
Often yes, but consumer-facing healthcare records may require an ESIGN consumer disclosure and documented consent per 15 U.S.C. §7001(c). HIPAA-covered entities must use vendors that support a BAA and secure PHI during electronic processing.
What witness or notary steps are required?
Requirements vary by state; some jurisdictions require one or two witnesses, others require notary or physician signature for medical orders. Verify applicable state statutes and institutional policies; use RON only where state law permits remote notarization and retention obligations are satisfied.
How should the signed form be stored?
Store signed forms in the patient's EMR as a tamper-evident PDF, maintain an audit trail, and enforce role-based access. Retain records per HIPAA (45 CFR §164.530(j)) and applicable state retention laws; keep originals accessible during care transitions.
Can EMS rely on this form in the field?
EMS reliance depends on state protocols and form compliance with jurisdictional requirements; some states require a physician-signed or state-issued DNR for EMS to withhold resuscitation. Provide portable, clearly labeled copies and notify EMS during transfers.
How do I revoke or change the order?
A competent patient can revoke or amend the DNH/DNI/DNR order by signing a new form, providing written revocation, or communicating with the care team per state law. Document revocations in the EMR and notify all involved providers immediately.

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