Oregon Do Not Resuscitate Order (DNR)
This Do Not Resuscitate (DNR) Order is created in accordance with Oregon state laws regarding advance directives and patient care.
Patient Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City: _______________________________
- State: Oregon
- Zip Code: __________________________
Health Care Representative Information:
- Name: ______________________________
- Relationship: ______________________
- Phone Number: _____________________
Patient's Wishes:
The patient wishes to have a Do Not Resuscitate Order in place. This means that in the event of cardiac arrest or respiratory failure, no resuscitative measures should be taken. This includes, but is not limited to:
- Chest compressions
- Defibrillation
- Intubation
- Advanced airway management
Signature:
By signing below, I confirm that I understand the implications of this DNR Order.
Patient Signature: ______________________________ Date: ___________
Health Care Representative Signature: ______________________________ Date: ___________
Witness Information:
- Name: ______________________________
- Signature: __________________________
- Date: ______________________________
This DNR Order should be kept in a location that is easily accessible and provided to all healthcare providers involved in the patient's care.