Oregon Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is created in accordance with Oregon state laws regarding advance directives and medical treatment preferences.
Patient Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- Phone Number: ______________________
Healthcare Representative (if applicable):
- Name: ______________________________
- Relationship: ________________________
- Phone Number: ______________________
Order Statement:
I, the undersigned, hereby declare that I do not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. I understand that this order will be honored by healthcare providers in accordance with Oregon law.
Patient Signature: ____________________________
Date: ____________________________
Witness Information:
- Name: ______________________________
- Signature: __________________________
- Date: ______________________________
This order should be kept in a prominent location and shared with all healthcare providers involved in the patient's care. It is recommended to provide copies to family members and the patient's primary care physician.
Important Note: This DNR order is valid only if it is signed by the patient or the patient's legal representative. Ensure that all signatures are completed for the order to be effective.