Tennessee Do Not Resuscitate Order Template
This Tennessee Do Not Resuscitate (DNR) Order Template is created in accordance with the provisions of the Tennessee Department of Health and is specifically designed to communicate the wishes of individuals who, due to medical conditions, prefer not to undergo cardiopulmonary resuscitation (CPR) in the event of a cardiac or respiratory arrest. This document should be discussed with and authorized by a licensed healthcare provider and kept in a place where it can be easily found in case of an emergency.
Patient Information:
- Full Name: _______________________________________________
- Date of Birth: ____________________________________________
- Patient Address: __________________________________________
- Primary Phone Number: _____________________________________
- Alternative Phone Number (Optional): ________________________
Medical Provider Information:
- Physician's Name: __________________________________________
- Medical Facility: __________________________________________
- Physician's Phone Number: _________________________________
- Physician's Signature: _____________________________________
- Date: _____________________________________________________
Healthcare Agent or Legal Representative (if applicable):
- Name: ______________________________________________________
- Relationship to Patient: ___________________________________
- Phone Number: _____________________________________________
- Signature (if applicable): __________________________________
- Date: _____________________________________________________
This order acknowledges that the patient has been fully informed of their condition, the nature and purpose of a Do Not Resuscitate Order, and the consequences of such an order. By signing this document, both the patient (or their legally authorized representative) and the physician affirm that the patient has chosen not to receive cardiopulmonary resuscitation in the event their heart and/or breathing stops.
Patient or Legally Authorized Representative’s Acknowledgment:
- I understand that this order will direct emergency medical personnel and healthcare providers to withhold cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest.
- I have discussed my condition and treatment options with my physician, who has answered all my questions regarding this DNR Order.
- I understand that this decision does not affect the provision of other emergency care, including oxygen, pain relief, and comfort care.
- I am aware that this order can be revoked at any time by myself or my legally authorized representative by physically destroying the document or by informing my physician or healthcare providers orally or in writing.
________________________________________ ________________________________
Patient’s or Legally Authorized Representative’s Signature
Date
Notice: Keep this original DNR Order in a visible and accessible location. A copy of this order should be presented to healthcare providers to be included in the patient's medical records.
