Dnr Request Form
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1
2(R.1/04)
CABINET FOR HEALTH AND FAMILY SERVICES
DEPARTMENT FOR COMMUNITY BASED SERVICES
DIVISION OF PROTECTION AND PERMANENCY
275 E. Main Street, 3E-F
Frankfort, KY 40621
(502) 564-6852
Fax: (502) 564-4653
TO:
FROM:
DATE:
SUBJECT:
DNR REQUEST FORM GUIDELINES
ATTACHED IS THE KENTUCKY CABINET FOR FAMILIES & CHILDREN DNR REQUEST FORM.
PLEASE FOLLOW THESE GUIDELINES
I
PERTINENT SECTIONS ARE TO BE COMPLETED. INCOMPLETE FORMS CANNOT BE
CONSIDERED AND WILL DELAY THE PROCESS.
II
SECTION B. OF THE FORM MUST BE COMPLETED AND SIGNED BY THE GUARDIANSHIP
CLIENT’S (STATE WARD’S) ATTENDING PHYSICIAN.
A SECOND PHYSICIAN MUST CONCUR WITH THE ATTENDING PHYSICIAN’S
RECOMMENDATION FOR DNR STATUS TO BE CONSIDERED.
III
ONLY PHYSICIANS MAY SIGN IN THE PHYSICIAN SIGNATURE BLOCKS.
IV
IT IS ESSENTIAL THAT THE PHYSICIAN NAMES AND TITLES ARE LEGIBLE.
V
ONCE THE FORM IS PROPERLY COMPLETED, PLEASE ATTACH ANY APPROPRIATE
SUPPORTING DOCUMENTATION, I.E., H&P, RECENT HOSPITAL DISCHARGE SUMMARY,
CONSULTATION NARRATIVES, DIAGNOSES LIST, PROGRESS NOTES (PROGNOSIS), OR
ANY OTHER INFORMATION THAT MAY IMPACT THE REQUEST.
VI
THE
CLIENT
MUST
HAVE
A
TERMINAL
CONDITION
OR
BE
PERMANENTLY
UNCONSCIOUS TO BE CONSIDERED FOR DNR STATUS.
VII
IF THE DNR COMMITTEE ADVISES THE STATE WARD (GUARDIANSHIP CLIENT) MEETS
THE CRITERIA FOR DNR, THE REQUESTING MEDICAL FACILITY WILL RECEIVE OFFICIAL
NOTIFICATION, WRITTEN AND/OR VERBAL, FROM THE CABINET.
REMEMBER - THE
REQUEST IS NOT APPROVED UNTIL THE REQUESTING FACILITY RECEIVES OFFICIAL
NOTIFICATION FROM THE CABINET.
THANKS IN ADVANCE FOR YOUR COOPERATION. IF YOU HAVE ANY QUESTIONS
PLEASE CALL_________________________ @___________________________.
An Equal Opportunity Employer M/F/D
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