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Maryland Do Not Resuscitate Form

The Maryland do not resuscitate form is provided by Maryland Institute for Emergency Medical Services Systems.

Maryland Do Not Resuscitate Form
Maryland Do Not Resuscitate Form
This f
orm is a physician's or nurse practitioner’s order under which EMS personnel will
not attempt resuscitation when
the patient named below is in cardiac arrest (no palpable pulse) or respiratory arrest (no spontaneous breathing). This
f
orm also instructs EMS personnel on interventions
bef
ore
arrest.
EMS personnel who see this order or a copy of it
or physical evidence of it (the attached bracelet or Medic Alert bracelet or necklace with DNR emblem) are to provide
care in accordance with this order and applicab
le Maryland Medical Protocols for EMS Providers. Unless a later
physician’s or nurse practitioner’s order relating to resuscitation has been issued, or unless the health care provider
reasonably believes the EMS/DNR order has been revoked,
every health care provider and facility is directed by law
to follow the EMS/DNR order by not resuscitating a patient who lacks a pulse or spontaneous respirations.
Patient Identifying Information
Name:
Date of Bir
th:
Physician’s or Nurse Practitioner's Order (Mark One)
I, the undersigned licensed ph
ysician or nurse practitioner, hereby order that emergency medical services
personnel provide care as specified below.
Option A: (DNI) Comprehensive Efforts to Prevent Cardiac/Respiratory Arrest Without Intubation
DNR if Arrest Occur
s-No CPR
Pr
ior to arrest, comfort care and all interventions allowed under The Maryland Medical Protocols for EMS
Pro
viders,
e
xcept intubation - Do Not Intubate (DNI)
.
No CPR if arrest occurs.
Option B: Supportive Care Prior to Cardiac/Respiratory Arrest
DNR if Arrest Occurs-No CPR
Prior to arrest, opening the airway by non-invasive means, providing passive oxygen, controlling external
bleeding, positioning for comfort and other comfort measures, splinting, pain medication by orders through
on-line medical direction, and tr
ansport as appropriate. No CPR if arrest occurs.
Physician’s or Nurse Practitioner's Certification (Mark One)
I hereby certify that this order is entered as a result of discussion with, and the informed consent of:
the patient; or
the patient’s health care agent as named in advance directive; or
the patient’s surrogate (including a legal guardian, if one has been appointed); or
if the patient is a minor, the patient's parent or legal guardian.
If none of these are indicated, I certify that I entered this order on the basis of:
instructions in the patient's advance directive; or
the certification of two physicians that CPR would be medically ineffective.
Physician’s or Nurse Practitioner's Signature and Identifying Information
Name:
Signature:
Date:
Maryland License Number:
Physician or Nurse Practitioner Phone Number:
If bracelet is to be used used, complete all information, including physician’s or nurse practitioner’s
signature, on each bracelet and separate at perforation.
Maryland Emergency Medical Services (EMS)
Do Not Resuscitate (DNR) and Medical Care Order
REVISED AUGUST 2010
Type or print legibly, have physician or nurse
practitioner sign, tear off strip, fold, trim and
insert in bracelet.
SUPPORTIVE CARE PRIOR TO
CARDIAC/RESPIRATORY ARREST,
DNR IF ARREST OCCURS - NO CPR
DO NOT CUT THROUGH INSERT- KEEP/RETURN WITH PATIENT
Pt. Name:
Pt. DOB: / /
MD/N.P
. Name:
Order
Date: / /
MD/N.P
. Sign:
MD/N.P. Ph.# ( )
COMPREHENSIVE EFFORTS TO PREVENT
CARDIAC/RESPIRATORY ARREST,
DNR IF ARREST OCCURS - NO CPR
A
(DNI)
B
Use of an EMS/DNR bracelet is OPTIONAL at the
discretion of the patient or authorized decision maker
.
fold here
Type or print legibly, have physician or nurse
practitioner sign, tear off strip, fold, trim and
insert in bracelet.
SUPPORTIVE CARE PRIOR TO
CARDIAC/RESPIRATORY ARREST,
DNR IF ARREST OCCURS - NO CPR
DO NOT CUT THROUGH INSERT- KEEP/RETURN WITH PATIENT
Pt. Name: Pt. DOB: / /
MD/N.P. Name: Order Date: / /
MD/N.P. Sign: MD/N.P. Ph.# ( )
COMPREHENSIVE EFFORTS TO PREVENT
CARDIA
C/RESPIRA
T
OR
Y ARREST
,
DNR IF ARREST OCCURS - NO CPR
A
(DNI)
B
Use of an EMS/DNR bracelet is OPTIONAL at the
discretion of the patient or authorized decision maker
.
fold here
Type or print legibly, have physician or nurse
practitioner sign, tear off strip, fold, trim and
insert in bracelet.
SUPPORTIVE CARE PRIOR TO
CARDIAC/RESPIRATORY ARREST,
DNR IF ARREST OCCURS - NO CPR
Pt. Name: Pt. DOB: / /
MD/N.P
. Name:
Order
Date: / /
MD/N.P
. Sign:
MD/N.P
. Ph.# ( )
COMPREHENSIVE EFFORTS TO PREVENT
CARDIAC/RESPIRATORY ARREST,
DNR IF ARREST OCCURS - NO CPR
A
(DNI)
B
Use of an EMS/DNR bracelet is OPTIONAL at the
discretion of the patient or authorized decision maker.
fold here
DO NOT CUT THROUGH INSERT- KEEP/RETURN WITH PATIENT
Maryland Do Not Resuscitate Form
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