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Massachusetts Do Not Resuscitate Form

The Massachusetts do not resuscitate form/Comfort Care is provided by Massachusetts Department of Public Health Office of Emergency Medical Services.

Massachusetts Do Not Resuscitate Form
Massachusetts Do Not Resuscitate Form
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
OFFICE OF EMERGENCY MEDICAL SERVICES
COMFORT CARE / DO NOT RESUSCITATE
(“DNR”) ORDER VERIFICATION
CCFORM_INSERT
2/2007
PATIENT
S LAST NAME
PATIENT’S FIRST NAME PATIENT’S MIDDLE NAME OR INITIAL
DATE OF BIRTH
(
MM/DD/YYYY
)
GENDER
M F
STREET OR RESIDENTIAL ADDRESS
CITY STATE ZIP CODE
(
5 or 9 di
g
its
)
LAST NAME OF GUARDIAN OR HEALTH CARE AGENT (If applicable)
FIRST NAME OF GUARDIAN OR HEALTH CARE AGENT MIDDLE NAME OR INITIAL
PATIENT/GUARDIAN/HHEALTH CARE AGENT STATEMENT (SIGNATURE AND DATE REQUIRED)
I
( patient guardian health care agent)
verify that the above named patient has a current and valid Do Not Resuscitate order (“DNR order”). I understand that by signing this
form, the DNR order, if current and valid, will be recognized in out-of-hospital settings and the COMFORT CARE / Do Not Resuscitate
Order Verification Protocol will be followed b
y
emer
g
enc
y
medical services
p
ersonnel.
Si
g
nature of Patient/Guardian/Health Care A
g
ent
Date
PHYSICIAN / NURSE PRACTICIONER (NP) / PHYSICIAN ASSISTANT (PA) VERIFICATION (PHYSICIAN / NP / PA SIGNATURE AND DATES
ALWAYS REQUIRED)
I am an attendin
g
ph
y
sician / NP / PA for the above named patient. I verif
y
that the above named patient has a current and valid Do Not Resuscitate
order, issued on
This DNR order does does not have an expiration date. If there is an expiration date, it is indicated below, and this
verification form also expires on that date.
I hereby direct that all emergency medical services personnel comply with the Massachusetts Department of Public Health, Office of Emergency Medical
Services’ COMFORT CARE / Do Not Resuscitate Order Verification Protocol with regard to the above named patient.
Si
nature of Ph
sician / NP / PA
Print Name of Physician / NP / PA
Effective Date of
CC / DNR Order
Verification
Expiration Date (if any) of DNR Order and CC/DNR Order
Verification
Address of Ph
y
sician / NP / PA
Tele
p
hone Number of Ph
y
sician / NP / PA
OPTIONAL BRACELET INSERTS
Attention Physician/NP/PA
Pat. Name
Gender M
F
Pat. DOB:
Expir. Date:
Tel.
- -
If used, enter information or print legibly. Physician/NP/ PA must
sign, tear off strip, fold, trim, and insert in bracelet.
Massachusetts
MD/NP/PA
Signature
Comfort Care/DNR Order Verification
Attention Physician/NP/PA
Pat. Name
Gender M
F
Pat. DOB:
Expir. Date:
Tel.
- -
If used, enter information or print legibly. Physician/NP/ PA must
sign, tear off strip, fold, trim, and insert in bracelet.
Massachusetts
MD/NP/PA
Signature
Comfort Care/DNR Order Verification
Attention Physician/NP/PA
Pat. Name
Gender M
F
Pat. DOB:
Expir. Date:
Tel.
- -
If used, enter information or print legibly. Physician/NP/ PA must
sign, tear off strip, fold, trim, and insert in bracelet.
Massachusetts
MD/NP/PA
Signature
Comfort Care/DNR Order Verification
Attention Physician/NP/PA
Pat. Name
Gender M
F
Pat. DOB:
Expir. Date:
Tel.
- -
If used, enter information or print legibly. Physician/NP/ PA must
sign, tear off strip, fold, trim, and insert in bracelet.
Massachusetts
MD/NP/PA
Signature
Comfort Care/DNR Order Verification
Massachusetts Do Not Resuscitate Form