Blank Do Not Resuscitate Order Template for North Carolina

North Carolina Do Not Resuscitate Order

In accordance with the North Carolina Do Not Resuscitate (DNR) Order guidelines, this document serves as a directive for healthcare professionals not to perform cardiopulmonary resuscitation (CPR) on the undersigned individual in the event of cardiac or respiratory arrest.

This order is made under the advisement of a licensed healthcare provider and is in compliance with North Carolina state laws, specifically under the North Carolina Medical Orders for Scope of Treatment (MOST) form protocol.

Patient Information:

• Full Name: ___________________________
• Date of Birth: ________________________
• Address: ______________________________
• City: _________________________________
• State: North Carolina
• Zip Code: ____________________________
• Telephone Number: _____________________

Medical Provider Information:

• Provider's Name: ________________________
• Provider's Title: ________________________
• Provider's Address: _____________________
• City: _________________________________
• State: North Carolina
• Zip Code: _____________________________
• Telephone Number: ______________________

By signing this order, the undersigned patient or their legally authorized representative acknowledges the decision to forego cardiopulmonary resuscitation (CPR) in circumstances of cardiac or respiratory arrest. It is understood that this does not prevent receiving other medical treatments deemed necessary for comfort and care.

This order is effective immediately upon signature and remains in effect until revoked or a new order is signed.

Patient or Legally Authorized Representative Signature:

Signature: ______________________________ Date: _______________

Witness Signature (if applicable):

Signature: ______________________________ Date: _______________

Healthcare Provider's Signature:

Signature: ______________________________ Date: _______________

Licensing Number: ________________________

This Do Not Resuscitate Order is duly executed in accordance with the laws of North Carolina and reflects the patient's wishes regarding resuscitation efforts.