Dnr Request Form (Page 2 of 2) in pdf

DNR REQUEST FORM

PLEASE PRINT OR TYPE

Client Name: _______________________________

Diagnoses:

_______

SSN:

_______________

Date of Birth:

_______________________________

ATTACH SUPPORTING DOCUMENTATION FROM THE MEDICAL RECORD

Is Hospice involved in the care of this patient? Yes______ No______

ONE OF THE FOLLOWING MUST BE CHECKED “YES” FOR DNR STATUS TO BE CONSIDERED:

1. Is the client in a terminal condition? Yes

No_____

(A terminal condition is defined as a condition caused by injury, disease or illness which in your estimation is

incurable and irreversible and will result in death within a relatively short time, and where the application of life

prolonging treatment would serve only to artificially prolong the dying process.)

2. Is the client permanently unconscious? Yes

No_____

(Permanently unconscious is defined as a condition characterized by an absence of cerebral cortical functions.)

REGARDLESS OF CODE STATUS, PALLIATIVE CARE WILL BE PROVIDED

(Palliative care is emotional and physical support for the relief of pain and suffering. It includes but is not limited to

nutrition, hydration and comfort measures unless specific authority to withhold/withdraw nutrition and hydration has been given.)

Recommended Code Status:

Withhold cardiopulmonary resuscitation/DNR

Comments:___________________________________________________________________________________

_________

____________________________________________________________________________________________

_________

________________

_____________

_______________________

SIGNATURE of Attending Physician

DATE

PHONE NUMBER

THIS FORM CANNOT BE PROCESSED WITHOUT

PLEASE PRINT OR TYPE NAME/TITLE

LEGIBLE TITLES AFTER THE PRINTED NAME

CONSULTATIVE OPINION

I have reviewed the medical record of and examined the above-named client.

I concur with above request.

_______I do not concur with the above request

Comments:

SIGNATURE of consulting Physician

DATE

PHONE NUMBER

THIS FORM CANNOT BE PROCESSED WITHOUT

PLEASE PRINT OR TYPE NAME/TITLE

LEGIBLE TITLES AFTER THE PRINTED NAME

GUARDIAN: PLEASE PROVIDE A SUMMARY OF CLIENT’S CURRENT STATUS (i.e., ABILITY TO PERFORM ACTIVITIES OF

DAILY LIVING (ambulation, transfer, feeding, toileting, bathing), ABILITY TO COMMUNICATE, PAIN STATUS, AND ANY OTHER

INFORMATION THAT MAY IMPACT THIS DECISION.

FOR STATISTICAL PURPOSES ONLY: AGE_____SEX_____RACE_____DATE OF APPOINTMENT_____/_____/______

_____________________________________________________________________

SIGNATURE:__________________________________________________________

Page 2 of 2

Dnr Request Form Page 2

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