DNR form

Document Name

“Nonhospial Order Not to Resuscitate”

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://tinyurl.com/djekqu

Who signs the form

The physician and the patient can consent to a DNR order orally or in writing, if two adult witnesses are present. When consent is given orally, one of he witnesses must be a physician affiliate with th hospital.

Patient Identification

New York EMS will honor the DNR Order form or a DNR bracelet issued by Medic Alert.

How do you obtain a DNR bracelet

Once the DNR form is signed, you can obtain a bracelet Medic Alert.

Revoking a DNR

You, or anyone who consents to a DNR order on your behalf, can remove the order by telling doctors, nurses or others about the decision. This need not be done in writing. Once informed of your wishes, your physician must record the DNR revocation in your chart, cancel the DNR order and make diligent efforts to retrieve all copies of your DNR form, as well as your DNR bracelet.

Photocopy

A photocopy is recognized as an authentic DNR form.

State info link

http://tinyurl.com/cksdvz
http://tinyurl.com/dna9dm

Other link

http://www.vialoflife.com/

DNR Bracelet links

DNR bracelets may be obtained from most companies that sell medical identification bracelets, provided they have a copy of your New York DNR form (DOH-3474) on file. Some bracelet sources include:

• Appomattox Drug Store, PO Box 489, Appomattox, VA 24522. Telephone 1-800-330-7225 ex. 102, or order on-line at http://tinyurl.com/cf5jdq
• Medic Alert Foundation International, Attn DNR, 2323 Colorado Avenue, Turlock, CA 95382 Phone: 1-888-633-4298, 3, 1 or ask for DNR. http://tinyurl.com/dlkluh

Medical Identification Jewelry (on-line orders only) at http://tinyurl.com/dk3yun or http://tinyurl.com/cs983u

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 form, DNR Order, do not resuscitate (DNR), do not resusitate, New York do not resuscitate form

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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

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Document Name:

UNIFORM DO-NOT-RESUSCITATE (DNR) ADVANCE DIRECTIVE

Where do you get the form

A physician must complete the form on your behalf. To obtain a copy of the IDPH Uniform DNR Advance Directive, you may request one from your health-care professional or facility. Copies also are available on the Illinois Department of Public Health’s Web site located at www.idph.state.il.us/public/books/advin.htm.

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

If you want to wear a DNR bracelet, you can order one from one of the linke listed below.

Revoking a DNR

The DNR order can be revoked in a variety of ways, such as by writing “VOID” in large letters across the front of the form. If you revoke a DNR order, you also should tell your family members, as well as each health-care professional and provider that has received a copy of the order. You may then choose not to have a DNR order, or you may choose to complete a new DNR order reflecting any changes you wish .

Photocopy

Photocopies of a completed IDPH Uniform DNR Advance Directive are valid.

State info link

http://tinyurl.com/ltm527

State statute link:

http://tinyurl.com/ddgby4

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. The original DNRO order MUST be printed on ORANGE paper, 8 ½ by 11.

Tagged as: DNR form, DNR Order, do not resuscitate (DNR), do not resusitate, Illinois do not resuscitate order

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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

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