Home > Legal > Will and Trust Template > Do Not Resuscitate Template > New Mexico Do Not Resuscitate Form > New Mexico Do Not Resuscitate Template

New Mexico Do Not Resuscitate Form

At Speedy Template, You can download New Mexico Do Not Resuscitate Form . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.

New Mexico Do Not Resuscitate Form
New Mexico Do Not Resuscitate Form
Page 1 of 3
Do Not Resuscitate Orders
Effective Date: 31 October 2002
Revised: 6/22/12
Distribution: All NMSBVI Staff
Kind: Board Policy
A Do Not Resuscitate (DNR) Order is an order issued by a physician, and signed by a patient, on a State of New
Mexico Approved form, indicating that resuscitative measures should not be performed on the patient in the
event of respiratory and/or cardiac arrest. It is the policy of the New Mexico School for the Blind & Visually
Impaired (NMSBVI) that staff who could be deemed health care providers” under the Uniform Health Care
Decision Act comply with validly executed DNR Orders so long as prior procedural steps are met to maximize
the appropriateness of a DNR Order in the unique school setting.
1. Presentation of a Do Not Resuscitate Order to NMSBVI.
a. When a Do Not Resuscitate (DNR) Order for a student is to be presented to NMSBVI, the
following criteria must be met:
(1) An original of the physician’s order, the original of the New Mexico Emergency Medical
Services (EMS) Do Not Resuscitate form, and the original NMSBVI Do Not Resuscitate form
must be completed by the physician and the parent(s)/legal guardian(s) and submitted to the
(2) When a student is 18 years of age, the DNR Order authorization must be made by the student,
unless custody of the student has been legally awarded to a guardian, or unless the student has
executed a power of attorney for health care which provides DNR Order authorization to the
b. A DNR Order is to be presented to the Superintendent who will initiate the following procedures:
(1) Upon receiving a DNR Order, a conference will be arranged with the parent(s)/guardian(s),
the local EMS providers and appropriate school staff and health providers to outline
expectations and procedures. A plan of care, which follows the physician’s orders, will be
developed and include goals, outcomes and delegation of care to be addressed in the student’s
Individualized Healthcare Plan. The healthcare plan will be written by the licensed school
nurse, in collaboration with the parent(s)/guardian(s), and is to be reviewed at the beginning
of each semester and as part of each IEP, and updated as needed. A DNR Order is deemed to
be revoked if it is not renewed as part of each IEP and/or 504 plan. All proceedings are to be
documented in the student’s health record.
(2) Original physician’s orders, EMS DNR form and NMSBVI DNR form must be kept with the
licensed school nurse as well as with the student. DNR Orders are to be reviewed at the
beginning of each semester and as part of each IEP.
(3) Student’s confidentiality will be maintained as much as possible. Only school administration,
school medical staff, student’s regular instructors, substitute instructors, and dormitory
personnel will be informed of the DNR Order. If the parent(s)/guardian(s) wish for additional
staff besides those listed to be informed of the DNR Order, the parent(s)/guardian(s) may so
specify. The parent(s)/guardian(s) will be advised that anyone who is not directly informed
about the DNR Order will initiate resuscitative efforts.
New Mexico Do Not Resuscitate Form