Can a DNR be signed electronically?

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

Are witnesses or notarization required?

Requirements vary by state and facility; some states or institutions require one or two witnesses or a notary for advance directives or surrogate authorizations—confirm local statute or policy.

Does HIPAA allow eSigning and sharing?

Yes, if the eSignature platform supports HIPAA protections and a Business Associate Agreement (BAA) is in place to safeguard protected health information.

How can a DNR be revoked?

A patient may revoke a DNR orally or in writing; clinicians should document revocation in the medical record and, if applicable, replace the order with a new signed directive.

What if family disputes the DNR?

Document the original consent conversation, surrogate authority, and clinician rationale. Institutional ethics and legal teams can assist when conflicts arise.

How do EMS see the DNR when dispatched?

Some regions use registries or document scanning into EHRs accessible to EMS; ensure local EMS processes are followed so out-of-hospital orders are recognized.

Electronic Signature
Templates
Healthcare
Healthcare DNR Consent Form

Healthcare DNR Consent Form

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

HEALTHCARE DO NOT RESUSCITATE (DNR) CONSENT FORM

Patient Information

Patient Name:

Date of Birth: Gender:

Address Primary Phone Emergency Contact

Insurance Information

Insurance Provider Policy & Group Numbers Subscriber Name (if different)

Medical History

Current Medications Allergies (including drug reactions) Prior Surgeries / Significant Procedures Chronic Conditions / Diagnosis

DNR Order and Scope

Explanation: A Do Not Resuscitate (DNR) order instructs health care providers not to perform cardiopulmonary resuscitation (CPR), advanced airway management, or electrical defibrillation if the patient experiences respiratory or cardiac arrest. This consent documents the patient's informed decision regarding resuscitation efforts.

Scope of DNR (select one or more as applicable):

In-hospital settings (hospital personnel) Out-of-hospital / Emergency Medical Services All health care settings

Informed Consent: Risks, Benefits, and Alternatives

I acknowledge that the clinician has explained the nature of a DNR order, its intended effect, reasonable foreseeable benefits, and the material risks, including but not limited to the possibility of death from withholding resuscitation, and the limitations of comfort measures that may accompany a DNR order. I understand the reasonable medical alternatives, including full resuscitative attempts and palliative care options.

I understand I have the right to refuse or withdraw this DNR order at any time, orally or in writing, and that withdrawal will be honored as promptly as reasonably practicable by the provider and, when appropriate, emergency responders.

Authorization Expiration Date (optional)

Privacy and Acknowledgment

I acknowledge that I have been informed of my privacy rights with respect to my medical information in connection with this DNR order. I authorize the health care team to access and disclose relevant health information as necessary to implement this order and to inform treating providers.

I acknowledge receipt of privacy and disclosure information related to this DNR order.

Attestations (Witness & Clinician)

Witnessed By (name printed):

Witness Contact/Phone:

Clinician Reviewing (name printed):

Clinician License/ID:

Clinician Orders Entered: Yes Date of Clinical Order (if entered):

Certification by Patient or Authorized Representative

I certify that I understand the contents of this document, that the DNR order as indicated reflects my informed decision, and that I give this consent voluntarily. If I am signing as an authorized representative, I certify that I am legally authorized to make health care decisions on behalf of the patient and that my authority is not inconsistent with applicable law.

If signing on behalf of patient, indicate relationship

Patient Name (print):

Signature:

Date:

What the Healthcare DNR Consent Form Is and Where It Fits

The Healthcare DNR Consent Form is a medical order or formal patient instruction documenting a decision to withhold cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It is completed by a patient or their authorized representative in consultation with treating clinicians and becomes part of the medical record. Depending on the state and facility, the form may be called a Do Not Resuscitate order, CPR directive, or be integrated into a POLST/MOLST document. Proper execution ensures clinicians and emergency responders follow the patient's end-of-life care preferences.

Why a Clear, Compliant DNR Consent Form Matters

A properly prepared Healthcare DNR Consent Form reduces ambiguity about resuscitation preferences, protects patient autonomy, and documents clinical decision-making. Clear documentation supports providers, reduces unwanted interventions, and helps ensure compliance with institutional policy and applicable law.

Who Completes and Relies on the DNR Consent Form

Proper signatory authority and accurate placement in the medical record are essential for the form to be effective in care settings.

Patients and Surrogates: Complete the form to record preferences and to authorize treatment limitations.
Physicians and Nurses: Confirm clinical suitability, document discussion, and countersign medical orders.
EMS and Hospital Staff: Use the form to guide resuscitation decisions during emergencies.

Core Elements Found in a Professional Healthcare DNR Consent Form

A professional DNR Consent Form combines clinical order language with clear signatory fields, witness or notary space when required, and space for documenting the informed consent discussion and clinical rationale.

Patient ID

Includes full legal name, date of birth, medical record number, and other identifiers to avoid misidentification and ensure the order attaches to the correct chart.

Clinical Order

Explicit instruction indicating CPR and advanced cardiac life support measures should not be performed, using clear clinical phrasing to guide treating teams.

Informed Consent

Section documenting that the patient or authorized decision‑maker received information about consequences, alternatives, and prognosis before consenting to a DNR order.

Signatures

Signature lines for the patient or surrogate, attending physician, and date/time stamps to record when the order became effective.

Witness / Notary

Space for witness signatures or notary acknowledgement where state law or facility policy requires additional authentication.

Revocation Clause

A clear statement describing how the patient can revoke or modify the DNR order and how that change is documented in the medical record.

Stepwise Process to Complete a Healthcare DNR Consent Form

Complete the form during a documented informed consent conversation and ensure all required fields and authentications are present.

01

Discuss Options: Explain prognosis, alternatives, and likely outcomes to the patient or surrogate.
02

Record Consent: Patient or surrogate signs the DNR form and dates the signature.
03

Clinician Order: Attending clinician signs to convert consent into a medical order.
04

Document Placement: File the completed form in the medical record and notify care teams and EMS if required.

Typical Workflow for Digital Completion and Routing

Digital workflows mirror in-person processes but add electronic auditing and optional identity checks; follow institutional policies for patient identity and consent.

Prepare Form: Upload the DNR template and place required fields for signature and clinician attestation.
Add Signers: List patient, surrogate, and clinician in the correct signing sequence.
Authenticate: Use SMS code, email link, or stronger verification as facility policy demands.
Store & Notify: Save the signed PDF to the EHR and notify relevant care teams and EMS as needed.

Technical Considerations for eSigning and Sharing

Confirm Business Associate Agreement (BAA) and audit logs are available to meet HIPAA and institutional policy needs.

File Formats: PDF or DOCX accepted; final record should be a tamper-evident PDF.
Integrations: Platform should integrate with EHRs and systems like Microsoft 365 and Google Workspace.
Security: TLS in transit and AES-256 at rest required for PHI handling.

Recommended Online Workflow Settings for a DNR Form

Configure these workflow settings to align the electronic process with clinical and legal requirements.

Field	Recommended Setting
Authentication	Email + SMS OTP or stronger identity proofing
Signer Order	Patient/surrogate then clinician countersign
BAA	BAA executed before PHI is uploaded or stored
Audit Trail	Enable full IP, timestamp, and action logs

Common Pitfalls to Avoid When Preparing a DNR Consent Form

Using vague language about interventions instead of explicit orders leads to confusion in emergencies and possible unwanted treatment.
Failing to record the decision-maker's legal authority (POA) can result in refusal to honor the signature and delay care decisions.
Not attaching the signed form to the patient chart or EHR causes the order to be unavailable when clinicians need it most.
Skipping required witness or notary steps where state or facility policy demands them undermines the document's enforceability.

Security and Compliance Elements to Include

Encryption: AES-256 at rest

Transport: TLS 1.2/1.3

Audit Trail: IP, timestamp, action log

BAA: Required for HIPAA PHI handling

Access Controls: Role-based access

Retention: Tamper-evident archival

Legal Risks and Consequences of Incorrect or Incomplete Forms

Invalid Order: May be ignored in emergencies

Civil Liability: Provider actions could trigger claims

Regulatory Breach: HIPAA violations risk penalties

Criminal Risk: Rare but possible in extreme cases

Care Delays: Treatment may be delayed for verification

Dispute: Family or surrogate conflicts can arise

How a DNR Consent Form Differs from Similar Advance Care Documents

Compare common end-of-life documents to determine which form aligns with the patient's goals and which commands clinical authority.

Document Type	Primary Use	Clinical Authority
DNR Order	no cpr	treating clinician order
POLST/MOLST	medical treatment preferences	portable clinician order
Advance Directive	long-term wishes	legal instruction for surrogate
Durable POA for Health	proxy decision-making	surrogate authority

eSignature Vendor Pricing and Feature Comparison Relevant to Healthcare DNR Forms

Compare per-user pricing and compliance capabilities for platforms commonly used to collect signed medical orders; signNow is listed first as the baseline for 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 vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Available	Available	Available	Available	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA)	Yes (BAA)	Yes (BAA)	Varies	Varies

Practical Examples of DNR Consent Form Use

Real-world scenarios show how properly completed DNR orders prevent unwanted interventions and clarify care during emergencies.

Hospital Inpatient Scenario

An elderly patient with advanced illness discussed goals with the team

clinician confirms lack of benefit from CPR
the signed DNR was entered into the EHR and honored during a subsequent arrest, avoiding invasive resuscitation and aligning care with patient wishes.

EMS Encounter

A community-dwelling patient registered a POLST with local EMS

EMS carried the registry information on dispatch screens
emergency responders followed the documented DNR order at the scene, preventing unwanted transport and interventions.

Frequently Asked Questions About Healthcare DNR Consent Forms

Answers to common questions explain legal validity, signature methods, witness needs, and revocation steps for Healthcare DNR Consent Forms.

Need help? Contact support

Can a DNR be signed electronically?
Yes. Electronic signatures are enforceable under the federal ESIGN Act (15 U.S.C. ch. 96) and UETA in most states, provided intent, consent, attribution, and record retention requirements are met.
Are witnesses or notarization required?
Requirements vary by state and facility; some states or institutions require one or two witnesses or a notary for advance directives or surrogate authorizations—confirm local statute or policy.
Does HIPAA allow eSigning and sharing?
Yes, if the eSignature platform supports HIPAA protections and a Business Associate Agreement (BAA) is in place to safeguard protected health information.
How can a DNR be revoked?
A patient may revoke a DNR orally or in writing; clinicians should document revocation in the medical record and, if applicable, replace the order with a new signed directive.
What if family disputes the DNR?
Document the original consent conversation, surrogate authority, and clinician rationale. Institutional ethics and legal teams can assist when conflicts arise.
How do EMS see the DNR when dispatched?
Some regions use registries or document scanning into EHRs accessible to EMS; ensure local EMS processes are followed so out-of-hospital orders are recognized.

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