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HIPAA PERMITS DISCLOSURE OF COLST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY
Patient Last Name
Patient First/Middle Initial
DNR/COLST
CLINICIAN
ORDERS
for DNR/CPR and OTHER LIFE SUSTAINING TREATMENT
FIRST follow these orders, THEN contact Clinician.
Date of Birth
(If patient/resident has no pulse and/or no respirations)
A
DO NOT RESUSCITATE (DNR)
□DNR/Do Not Attempt Resuscitation
(Allow Natural Death)
CARDIOPULMONARY RESUSCITATION (CPR)
□
CPR/Attempt Resuscitation
For patient who is breathing and/or has a pulse, GO TO SECTION B – G, PAGE 2 FOR OTHER
INSTRUCTIONS. CLINICIANS MUST COMPLETE SECTIONS A-1 THROUGH A-5
A-1 Basis for DNR Order
Informed Consent - Complete Section A-2
Futility - Complete Section A-3
A-2 Informed Consent
Informed Consent for this DO NOT RESUSCITATE (DNR) Order has been obtained from: