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Healthcare DNR Document

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Healthcare Do-Not-Resuscitate (DNR) Order

This Do-Not-Resuscitate (DNR) Order is an instruction to withhold cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. When properly completed and signed by the patient or the patient's authorized representative, and acknowledged by the attending clinician, this order shall be placed in the medical record and honored by health care providers in all settings unless lawfully revoked or superseded by a subsequent valid order.

Patient Information

Patient Name:    Date of Birth:

Emergency Contact

DNR Order Statement

I direct that the following order(s) apply in the event of cardiac or respiratory arrest (check all that apply):

 Do-Not-Resuscitate — Withhold CPR: Do not initiate cardiopulmonary resuscitation (chest compressions, defibrillation, endotracheal intubation, or advanced airway management).

 Allow Natural Death: Focus on comfort and allow natural death; withhold CPR while continuing other indicated medical treatments unless otherwise specified.

 Comfort Measures Only (CMO): Focus exclusively on symptom control and comfort; withhold CPR and other life-prolonging interventions.

Decision-Making Capacity and Representative

 Patient has decision-making capacity

 Patient lacks capacity; decision made by authorized representative

Clinician Assessment and Attestation

By completing the fields below, the attending clinician attests that they have discussed the nature and medical consequences of this DNR order with the patient or the patient's authorized representative, that risks and benefits were explained, and that the patient/representative understands and wishes this order to be entered into the medical record.

Practitioner Orders

Practitioner confirms and orders that, consistent with the patient's wishes indicated above, the following apply (check all that apply):

 Order to withhold CPR in the event of cardiac or respiratory arrest.

 Order to allow natural death while continuing other indicated treatments unless otherwise limited.

 Order for comfort measures only; withhold CPR and other life-prolonging interventions.

Revocation and Amendments

The patient or the patient's authorized representative may revoke or amend this DNR Order at any time by providing a written revocation or by communicating the revocation to the treating clinician. Any revocation must be documented in the medical record and a new order issued if appropriate.

Privacy Acknowledgment

 I acknowledge that information contained in this document will be part of the patient's medical record and may be disclosed to health care providers as necessary to carry out the instructions contained herein.

Witness (if required)

Certification: By signing below, the signer affirms that the information provided is accurate to the best of their knowledge, that they understand the legal effect of this DNR Order, and that they have authority to make medical decisions for the patient if signing as an authorized representative. This order shall be honored in all settings and by all licensed health care providers unless lawfully revoked or superseded.

Patient:

By:

Date:

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What the Healthcare DNR Document Is

A Healthcare DNR Document (Do Not Resuscitate order) is a signed medical order instructing clinicians not to perform cardiopulmonary resuscitation (CPR) if a patient has no pulse or is not breathing. It is typically issued by a physician or advanced practice provider with the patient’s informed consent, and it can exist as a standalone medical order or as part of an advance directive or POLST/MOLST form depending on the jurisdiction.

Why a Clear DNR Document Matters

A properly completed Healthcare DNR Document ensures patient treatment preferences are recorded as a medical order, reduces uncertainty in emergencies, and helps clinicians follow legally enforceable instructions consistent with state law and medical ethics.

Why a Clear DNR Document Matters

Step-by-step: completing a Healthcare DNR Document

Follow these five practical steps to prepare, sign, and ensure the DNR order is honored by care teams and documented in the medical record.

  • 01
    Prepare: Gather ID, medical record number, and clinician details.
  • 02
    Discuss: Confirm preferences with clinician and document informed consent.
  • 03
    Order: Clinician completes and signs the official medical order form.
  • 04
    Record: File order in the medical chart and electronic health record.

Core components included in a professional Healthcare DNR Document

A complete DNR form combines patient identification, a clear medical order, documented consent, signer authority, effective timing, and instructions for distribution to care teams and emergency services.

Patient ID

Full legal name, date of birth, and medical record number to uniquely associate the order with the correct patient record.

Medical Order

Explicit language stating that CPR and advanced cardiac life support should not be performed if the patient has no pulse or respirations.

Informed Consent

A statement that the patient or authorized decision-maker discussed benefits, risks, and alternatives with the prescribing clinician.

Signer Authority

Signature and printed name of the patient or legally authorized surrogate, and clinician signature with license number.

Effective Period

Order effective date and any expiration or review date; instructions for renewal or revocation if applicable.

Distribution Notes

How and where the signed order is placed (EHR, physical chart, emergency wristband, POLST registry where applicable).

Essential information fields to include on the form

Patient Name: Full legal name
Date of Birth: MM/DD/YYYY
Medical Record #: Facility MRN
Ordering Clinician: Name and license
Signature Date: MM/DD/YYYY
Proxy Relationship: If signed by surrogate

Where to file and how the DNR order is routed

After signing, the order must be placed in the medical record and communicated to relevant teams so it can be located in an emergency. Follow facility policy for EHR entry and physical placement.

  • EHR Entry: Scanner or EHR order entry links to patient chart.
  • Chart Placement: Place original order in the front of the paper chart.
  • EMS Notification: Provide copies or registry entries for emergency responders.
  • Registry Filing: Where available, submit to state POLST/DNR registry.

Customizing an online DNR workflow for clinical use

Set up fields and authentication to match facility policy and legal requirements before collecting signatures electronically.

Field Configuration
Patient ID Field Required, autofill from EHR
Clinician Signature Required, include license number
Patient/Proxy Signature Required, include relationship field
Audit Trail Enable timestamps and IP logging

Electronic submission and platform requirements

Pick an eSignature platform that supports secure authentication, audit trails, and any required compliance addenda for protected health information.

  • Authentication: Email, SMS, or KBA
  • Audit Trail: Timestamps and logs
  • Integrations: EHR and document systems

Timing considerations and review expectations

DNR orders should be reviewed on transfer of care, at major clinical status changes, and per facility policy. Keep effective dates clearly recorded to prevent conflicts with prior orders.

Initial Execution:

Signed when patient choice is confirmed

On Transfer:

Review and re-document at transfer or discharge

Clinical Change:

Reassess after significant health events

Annual Review:

Follow facility policy for periodic review

Immediate Revocation:

Patient may revoke at any time

Key milestones from discussion to active order

A typical sequence moves from conversation to documentation, clinician order, record entry, and distribution to responders and registries.

01

Conversation

Clinician documents the patient’s preferences and alternatives.

02

Order Entry

Clinician signs the formal medical order in EHR or on paper.

03

Record Update

Order is filed in the chart and visible in the EHR summary.

04

Distribution

Provide copies to patient, proxy, EMS, and registry if applicable.

Risks and legal consequences of incorrect or missing orders

Medical Error: Unclear orders can lead to unwanted resuscitation
Legal Challenge: Invalid signatures risk non-enforcement
Delays in Care: Missing documentation can delay EMS adherence
Regulatory Noncompliance: HIPAA or state law violations possible
Proxy Disputes: Conflicts over authority may arise
Recordkeeping: Insufficient retention may breach rules

Common preparation mistakes to avoid

  • Using initials without a full signature or omitting the clinician’s license number can make the order difficult to validate in clinical settings.
  • Failing to include the exact effective date or leaving expiration fields blank can create conflicting orders in the medical record.
  • Having different names between the order and the patient’s chart, such as missing middle names or maiden names, can prevent linkage to the correct chart.
  • Not distributing a copy to EMS, the patient, and the receiving facility increases the risk that the order will not be honored in emergencies.

Who typically completes or signs a Healthcare DNR Document

Confirm local policy for surrogate authority and clinician ordering privileges; documentation of consent and signer authority should be explicit on the form.

  • Patients with decision-making capacity who wish to decline resuscitation.
  • Legally authorized representatives or surrogates acting under state authority.
  • Ordering clinicians (physicians, NP, PA) who enter the medical order.

Typical signer roles and responsibilities

Patient (Signatory)

A competent adult patient signs to decline resuscitation after informed discussion; the entry should include the patient’s printed name, signature, date, and any stated limitations or contextual notes.

Clinician (Ordering)

A licensed clinician documents the DNR as a medical order, signs with license number, and notes the discussion; clinician signature converts patient preference into an actionable clinical instruction.

Real-world examples of DNR use in clinical settings

These condensed case descriptions show typical scenarios and practical considerations for documenting DNR orders in care workflows.

Hospital Admission Example

A hospitalized patient discusses end-of-life wishes with the care team and signs a DNR order

  • Clinician enters the order into the EHR
  • The order is flagged on transfer notes and a printed copy is placed at the front of the chart for bedside teams and on-call staff to see.

Home Hospice Example

A hospice patient and family agree not to pursue resuscitation; the hospice clinician documents and signs a DNR order

  • The order is placed in the home record and a copy is provided to family
  • EMS is given a registry entry and a printed copy, improving compliance during emergency calls.

eSignature vendor comparison for Health Care DNR forms

Basic pricing and feature availability for common eSignature vendors. Confirm plan details and HIPAA options with each vendor before implementation.

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
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions about Healthcare DNR Documents

Answers to common questions about validity, signing authority, updates, and electronic submission for DNR orders in U.S. healthcare settings.


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