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New Jersey Do Not Resuscitate Form

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New Jersey do not resuscitate form is provided by State of New Jersey Department of Health.

New Jersey Do Not Resuscitate Form Page 2
New Jersey Do Not Resuscitate Form
ALL PATIENTS HAVE THE RIGHT TO MAKE HEALTHCARE DECISIONS
INCLUDING THE RIGHT TO ACCEPT OR
REFUSE LIFE-SAVING MEDICAL TREATMENT.
1. ASSESS THE PATIENT FOR THE ABSENCE OF BREATHING
AND/OR HEARTBEAT.
2. IF THE PATIENT IS NOT
IN CARDIAC AND/OR RESPIRATORY
ARREST, PROVIDE ALL
NECESSARY CARE, INCLUDING TRANSPORT
IF REQUIRED.
3. IF THE PATIENT IS
IN CARDIAC AND/OR RESPIRATORY ARREST,
DO NOT INITIATE CPR
AND RESUSCITATIVE EFFORTS.
4. FOLLOW LOCAL EMS PROTOCOLS FOR PRONOUNCEMENT.
5. DOCUMENT ALL PERTINENT INFORMATION ON YOUR RUN
SHEET AND ATTACH A COPY OF THIS OUT-OF-HOSPITAL DNR
ORDER.
6 ONLY
THE INDIVIDUAL(S) (PATIENT, SURROGATE, OR PHYSICIAN)
WHO SIGNED THIS FORM MAY RESCIND IT AT ANY TIME.
7. PHOTOCOPIES OF THIS DOCUMENT ARE PERMITTED
AND
SHALL BE HONORED AT ALL TIMES.
THIS DOCUMENT, ITS INTENT AND ASSOCIATED POLICIES ARE SUPPORTED BY:
Medical Society of New Jersey
New Jersey Department of Health and Senior Services
New Jersey Chapter, American College of Emergency Physicians
New Jersey State Nurses Association
New Jersey HealthDecisions
New Jersey Association of Osteopathic Physicians and Surgeons
Academy of Medicine of New Jersey
New Jersey MICU Program Administrators Association
MICU Advisory Council
New Jersey State First Aid Council
IF THERE ARE ANY QUESTIONS CONCERNING THE TREATMENT
AND/OR PRONOUNCEMENT OF THIS PATIENT, CALL:
CONTACT PERSON:_____________________________TELEPHONE:( ) __________- ________________
AGENCY:____________________________________________________________________________________
New Jersey Do Not Resuscitate Form
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