- Document Name
- Comfort Care/Do Not Resuscitate Order Verification
OR
Custom Care/Do Not Resuscitate Order Verification With Bracelet
- Where do you get the form
- A physician must complete a DNR form on your behalf. If you want to order a bracelet, the physician will complete the DNR Order Verification With Bracelet form.
If your physician does not have a form, click here:
http://tinyurl.com/c627vx.
- Who signs the form
- The form is signed by the physician, the patient, and two witnesses. The DNR Verification with Bracelet form must be printed on 8 1/2 inch by 14 inch legal size paper.
- Patient Identification
- The Comfort Care/DNR verification is the only document that EMS personnel can use to verify a DNR order is valid.
- How do you obtain a DNR bracelet
- Your physician must order a DNR bracelet for you.
- Revoking a DNR
- An EMS/DNR Order may be revoked at any time by the patient’s request for resuscitation made directly to responding emergency medical services personnel OR by the physical cancellation or destruction of all EMS/DNR Order forms, bracelets, and necklaces with the consent of the patient or the authorized decision maker signing the EMS/DNR Order. Destruction of an EMS/DNR Order, bracelet, or necklaces without consent carries penalties under the Health Care Decision Act.
- Photocopy
- Photocopies of the form or the bracelet inserts are not considered authentic DNR documents. If you need a document at more than one location, create multiple original documents.
- State info link
- http://tinyurl.com/c627vx
- Other links
- http://www.vialoflife.com/
- DNR Bracelet links
- Your physician must order a DNR braclet on your behalf.
- Special Notes
- Order a Vial of Life decal for your front door. The decal informs Emergency Medical Services team a DNR has been prepared and can be found in your refrigerator. The Customer Care/Do Not Resuscitate Order Verification assumes the patient has completed a separate DNR form. The DNR Order Verification form provides a way to document the existence of a DNR in out of hospital situations.
Tagged as:
DNR bracelet,
DNR form,
DNR Order,
do not resuscitate (DNR),
do not resusicate,
Massachusetts DNR
- Document Name
-
“Out of Hospital DNR Order”
- Where do you get the form
-
Only a licensed physician can complete the form. and he or she . should have a copy of the DNR Order. If you need to provide a for to your physician, click here: http://www.njha.com/ps/pdf/dnr.pdf The form can be found on pages 13-14.
- Who signs the form
-
The physician and the patient.
- Patient Identification
-
New Jersey EMS will honor the DNR Order form or a DNR bracelet that is worn on the patient’s ankle or wrist, has an insert displaying the patient’s name, physician name and date of the DNR, and has never been cut or removed.
- How do you obtain a DNR bracelet
- Once the DNR form is signed, you can obtain a bracelet from your physician or any health care facility licensed by the state of New Jersey (hospitals, long term care facilities, nursing homes, hospice). Call 1-973-857-5552 for more information.
- Revoking a DNR
- A DNR order may be revoked by the patient by removing the bracelet, verbally requesting the DNR be revoked, or destroying the DNR form. The patient should report the revocation of the DNR to their physician.
- Photocopy
-
A photocopy is recognized as an authentic DNR form.
- State info link
- http://www.njha.com/ps/pdf/dnr.pdf
- Other links
- http://www.vialoflife.com/
- DNR Bracelet links
- Once you complete the DNR form, you can order a DNR bracelet. There is no requirement for information from the form to be available on the bracelet.
- Special Notes
- Order a Vial of Life decal for your front door. The decal informs Emergency Medical Services team a DNR has been prepared and can be found in your refrigerator.
Tagged as:
DNR bracelet,
DNR form,
do not resuscitate (DNR),
do not resusitate,
New Jersey do not resuscitate order
- Document Name
- EMS Do Not Resuscitate and Medical Care Order.
- Where do you get the form
- A physician must complete the form on your behalf. You can print out the form: http://www.miemss.org/home/Portals/0/Docs/OtherPDFs/DNRorder_form.pdf
- Who signs the form
- The form is signed by the physician, the patient, and two witnesses and printed on brightly cooolored ORANGE paper.
- Patient Identification
- There is no requirement for a patient to wear a DNR identification bracelet. EMS will honor a DNR form signed by a physician, patient and 2 witnesses.
- How do you obtain a DNR bracelet
- The DNR form includes information about ordering a DNR bracelet. If a vinyl bracelet is to be used, have the physician sign the bracelet inserts at the bottom of the EMS/DNR. If a metal bracelet or necklace is desired contact Medic Alert® at 1-800-432-5378. They will send you the application and information. They will require a copy of this order in order to process your request.
If a vinyl bracelet will be used, be sure the insert has been completed and signed, tear the bracelet insert off of the original form, fold it, trim it along the dashed line, and insert it in the vinyl EMS/DNR bracelet that has been provided. The bracelet may be worn about the wrist, hung from a necklace, or pinned to clothing.
- Revoking a DNR
- An EMS/DNR Order may be revoked at any time by the patient’s request for resuscitation made directly to responding emergency medical services personnel OR by the physical cancellation or destruction of al l EMS/DNR Order forms, bracelets, and necklaces with the consent of the patient or the authorized decision maker signing the EMS/DNR Order. Destruction of an EMS/DNR Order, bracelet, or necklaces without consent carries penalties under the Health Care Decision Act.
- Photocopy
- Photocopies of a completed DNR form are valid.
- State info link
- http://www.miemss.org/home/PublicInformation/DNRDoNotResuscitate/tabid/118/Default.aspx
- Other links
- http://www.vialoflife.com/
- DNR Bracelet links:
- You can elect to purchase a DNR bracelet at these links.
- Special Notes
- Order a Vial of Life decal for your front door. The decal informs Emergency Medical Services team a DNR has been prepared and can be found in your refrigerator.
Tagged as:
DNR bracelet,
DNR form,
DNR Order,
do not resuscitate (DNR),
do not resusitate,
Maryland do not resuscitate order
