Ohio Do Not Resuscitate Order Template

Ohio Do Not Resuscitate (DNR) Order Template

This document is prepared in accordance with the laws of the State of Ohio, specifically the Ohio Do Not Resuscitate Protocol. It is a legal form that lets people choose not to have CPR (cardiopulmonary resuscitation) or advanced cardiac life support if their heart stops or if they stop breathing.

Completion of this form should be done after thorough discussion with your healthcare provider about the implications of a DNR order. Ensure all information is accurate and complete.

Patient Information

• Full Name: ____________________________________________________
• Date of Birth: ____ / ____ / ________
• Address: ________________________________________________________
• City: ______________________ State: Ohio Zip Code: ___________
• Phone Number: _______________________________________________

Healthcare Provider Information

• Provider Name: _______________________________________________
• Provider Title: ______________________________________________
• Facility Name (if applicable): _________________________________
• Address: ________________________________________________________
• City: ______________________ State: Ohio Zip Code: ___________
• Phone Number: _______________________________________________

Ohio DNR Order

I, ______________________(patient name), understand the full implications of issuing a Do Not Resuscitate (DNR) order. I direct that in the event my heart stops beating or I stop breathing, no medical procedure to restart breathing or heart functioning shall be instituted.

I revoke any previous wishes inconsistent with this DNR Order. This document will remain in effect until I cancel it.

Signature Section

I hereby declare under the penalty of perjury that I am fully informed of the nature and effect of this document and that I understand its significance.

1. Patient or Legally Authorized Representative Signature: ______________________________________________
2. Date: ____ / ____ / ________
3. Witness Signature: _________________________________________________
4. Date: ____ / ____ / ________
5. Healthcare Provider Signature: ________________________________________
6. Date: ____ / ____ / ________

Instructions for Healthcare Providers

Validate the authenticity of this document and ensure it conforms with current Ohio law. Enter this DNR order into the patient's medical record, and discuss its implications and responsibilities with all healthcare personnel involved in the patient's care.

Remember, a DNR order is a legal decision made by the patient or their legally authorized representative. It requires the respect and understanding of all healthcare providers involved in the patient's care.