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Healthcare Do Not Resuscitate Form

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Healthcare Do Not Resuscitate Form

Patient Information

Patient Name:

Insurance Information

Medical History

Do Not Resuscitate Order — Directions

I direct that if the patient's heart stops beating and/or the patient stops breathing, the following orders apply. These orders are to be followed by medical personnel unless superseded by a subsequently executed directive signed by the patient:

No cardiopulmonary resuscitation (CPR): Do not perform chest compressions, rescue breathing, or external defibrillation.

No advanced airway management or endotracheal intubation.

Do not use electrical cardioversion or defibrillation.

Comfort measures only: Provide care to relieve pain and suffering; do not initiate life-prolonging treatments.

Scope of Order

This order applies in the following setting(s):

Inpatient / Hospital

Out-of-hospital (EMS / ambulance)

All settings

Emergency Instructions and Clinical Rationale

Voluntariness, Revocation, and Legal Effect

I understand that this Do Not Resuscitate order is voluntary. By signing below I authorize health care personnel to follow the directions indicated above. I understand that:

  • These orders instruct clinicians not to initiate resuscitative measures specified above in the event of cardiac or respiratory arrest.
  • I may revoke this order at any time by providing a written or verbal statement to a treating clinician. Reinstatement requires a new written order.
  • The order remains in effect until revoked or replaced by a subsequently executed, properly signed directive.

Acknowledgement

I acknowledge that I have been informed of the nature and consequences of this DNR order, that alternatives were explained, and that my questions were answered.

I have discussed this decision with my physician or authorized clinician.

I understand the medical consequences of this order.

HIPAA / Privacy Acknowledgment

By signing this form I authorize disclosure of relevant medical information to emergency responders and treating clinicians for the purposes of implementing this DNR order.

I acknowledge and authorize the necessary release of information for implementation of this order.

Clinician Information (for record)

Declaration and Signature

I declare that I am the patient named in this form, or I am the duly authorized legal representative of the patient. I affirm that the information and instructions in this document reflect my wishes, are given freely, and are intended to be legally effective.

Patient Printed Name:

Signature:

Date:

Relationship to Patient (if not patient):

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What the Healthcare Do Not Resuscitate Form Is

A Healthcare Do Not Resuscitate Form documents a patient's clear instruction to decline cardiopulmonary resuscitation (CPR) and related life-sustaining interventions in the event of cardiac or respiratory arrest. It is a medical order entered into the patient chart or an official state form (or POLST in some states) and must reflect patient capacity, informed consent, and the attending clinician's concurrence. The form guides clinical teams and emergency responders on withholding resuscitative measures consistent with the patient's preferences and applicable state statutes and facility policies.

Why a Clear DNR Form Matters

A properly completed Healthcare Do Not Resuscitate Form ensures patient wishes are recorded, reduces unwanted interventions, and clarifies clinical decision-making during emergencies. It supports patient autonomy while protecting providers who follow documented medical orders from liability under applicable state law and professional standards.

Why a Clear DNR Form Matters

Who typically completes or relies on a DNR Form

Several distinct groups create, sign, or depend on the DNR form to honor patient preferences and coordinate care.

  • Patients with advanced illness or serious chronic conditions who wish to decline resuscitation.
  • Attending physicians or advanced practice clinicians who enter the medical order in the chart.
  • Family members and surrogates when the patient lacks decisional capacity and legal authority exists.

Accurate completion and distribution to the medical record, EMS, and relevant caregivers ensure the order is visible and actionable in urgent situations.

Primary signers and certifying professionals

Patient — Primary

The patient signs when they have decision-making capacity; signature documents informed refusal of resuscitation and should be witnessed or notarized per state rules when required.

Physician — Certifier

A licensed clinician enters or signs the medical order to confirm clinical appropriateness; their signature links the DNR to the patient chart and institutional policies.

Essential data elements for the form

Patient Name: Full legal name
Date of Birth: MM/DD/YYYY
Medical Record #: Hospital or clinic ID
Ordering Clinician: Name and license
Specific Instructions: Scope of interventions
Signatures: Patient/surrogate and clinician

Risks and legal consequences of errors

Invalid Consent: May render order unenforceable
Wrong Patient: Clinical harm and liability
Missing Clinician Signature: Order may lack authority
Improper Witnessing: State noncompliance risk
HIPAA Violations: Improper sharing risks penalties
Failure to Communicate: EMS may act inconsistently

Common preparation errors to avoid

  • Using abbreviations or incomplete names that create uncertainty about the patient identity and can delay or invalidate the order.
  • Failing to document capacity or informed refusal—absence of capacity findings can lead to challenges from family or ethical review.
  • Not routing the executed order to the electronic health record, bedside chart, and emergency services leads to the order being unavailable in crises.
  • Assuming a verbal instruction suffices—most facilities require a signed written order and clinician confirmation for enforceability.

Step-by-step: Completing a Healthcare DNR Form

Follow these sequential steps to ensure a legally sound and clinically actionable DNR order.

  • 01
    Confirm Capacity: Assess and document patient decision-making ability.
  • 02
    Discuss Options: Explain interventions, outcomes, and alternatives.
  • 03
    Complete Form: Enter patient info, clear instructions, and dates.
  • 04
    Route and File: Place order in chart and notify EMS if applicable.

How the DNR order is used in clinical workflows

A DNR order becomes an actionable clinical instruction once signed and recorded; these key steps show typical information flow.

  • Order Entry: Clinician documents DNR in the medical record.
  • Patient Copy: Patient or surrogate receives a copy.
  • Care Team Notification: Nursing, consultants, and pharmacy are informed.
  • EMS Visibility: Order is shared with emergency responders when appropriate.

Key sections a professional DNR Form should include

A complete form is concise but covers clinical, legal, and administrative elements so providers can act confidently during an emergency.

Identification

Patient full legal name, date of birth, medical record number, and contact details to eliminate identity uncertainty.

Clinical Directive

Clear statement declining CPR and related interventions, with any allowable exceptions or scope limitations spelled out.

Capacity Statement

Documentation that the patient had capacity and provided informed refusal, or identification of the authorized surrogate.

Clinician Attestation

Name, license number, date, and signature from the ordering physician or qualified clinician confirming the order.

Witnessing/Notary

Witness or notary lines when required by state law, including witness names and signatures where applicable.

Distribution Log

Record of copies given to patient, family, facility chart, EMS, and any registry entries for traceability.

Customizing an online DNR form for your facility

Configure digital fields and routing to match clinical and legal requirements, then test the workflow before full use.

Field Configuration
Patient Identifier Auto-populate from EHR via integration
Capacity Checkbox Required field with clinician attestation
Witness Lines Conditional display by state selection
Distribution Automated copy to chart and EMS

Technical considerations for eSigning and storage

Use a platform that supports HIPAA controls, audit trails, and flexible witness or notary workflows to ensure legal and operational compliance.

  • Authentication: Email, SMS code, or stronger signer verification
  • Audit Trail: Timestamps, IP, and action history
  • Integrations: Connectors for EHRs and cloud storage

Ensure the vendor can sign a Business Associate Agreement (BAA) for HIPAA-covered environments and can retain tamper-evident records.

Sample eSignature vendor comparison for healthcare forms

Comparison of starting price and core capabilities across common eSignature vendors; signNow appears first per guidance.

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) Yes Yes Yes No
HIPAA Compliant Yes Yes Yes No No

Practical tips for accurate and efficient DNR completion

Adhering to these practices reduces delays and increases the likelihood that patient wishes will be honored across care settings.

Use Standardized Forms
Adopt state-approved DNR or POLST templates to ensure required language and witness/notary blocks are present and recognized by EMS.
Document Capacity Clearly
Record the patient's decision-making capacity and the information provided; cite clinical assessment to support validity if contested.
Ensure Accessibility
Place the signed order in the EHR, at bedside, and in any applicable registry so emergency responders and on-call clinicians can find it.
Review and Update
Reconfirm DNR status after significant clinical changes; update the form and distribute new copies to reduce confusion.

Timing and review expectations for DNR orders

While DNR orders take effect upon valid execution, timely communication and periodic review help keep orders current and enforceable.

Effective Immediately:

A validly signed order is effective upon signing unless the form states otherwise

Charting Requirement:

Enter the order in the EHR at once so bedside staff and on-call clinicians can comply

EMS Notification:

Provide copies or registry entries to EMS where state systems support prehospital recognition

Periodic Review:

Review after major health changes or at scheduled intervals per facility policy

Revocation Timing:

Revocation takes effect when communicated and documented according to policy

Real-world scenarios where a DNR form matters

These anonymized examples illustrate common contexts and outcomes when a DNR is used correctly.

Hospitalized Patient

An elderly patient with advanced heart failure completed a DNR after goals-of-care discussion

  • The clinician documented capacity and entered the order in the EHR
  • Result: ICU avoided unwanted CPR and care focused on comfort measures, consistent with the patient's wishes.

Long-term Care Resident

A nursing home resident and family agreed to a DNR during a care planning meeting

  • Staff recorded the surrogate authorization and obtained two witness signatures per state rule
  • Result: EMS honored the order on transfer and palliative services were prioritized.

Frequently asked questions about the Healthcare DNR Form

Answers to common legal and practical questions about completing, signing, and enforcing a DNR order in the United States.


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