DNR form – ADC

DO NOT RESUSCITATE (DNR)

Do not call CPR/Code Blue Team

Do not insert endotracheal intubation

Do not initiate chest compressions

Do not use defibrilation/counter shock

Do not use mechanical ventilation

Do not administer ACLS medications (eg. Vasopessors, Antiarrhythmic)

ICU Admission:

Yes No

Intubation and Ventiliation:

Yes No

Non-invasive Ventilation:

Yes No

Other:(Please describe below):

Yes No

Physician name & Sign:

ID No.

Data:

Time:

Physician name & Sign:

ID No.

Data:

Time:

Physician name & Sign:

ID No.

Data:

Time:

The patient remained in the hospital or discharged & re-admitted, the most recent orders for "DNR" form in effect and should be reviewed. A new form should be written if more than 6 months has elapsed since he previous order was written and the old form should be voided.
VOID: Please a diagonal line across the whole form and write in large letters "VOID". Print and sign our name, include your computer number and date & Time. It should be done by the attending physician.
The old form voided is to be kept in the patient's medical file.