North Carolina Do Not Resuscitate Order
This Do Not Resuscitate (DNR) Order is made in accordance with North Carolina state laws regarding end-of-life care and patient autonomy.
Patient Information:
- Name: __________________________
- Date of Birth: ___________________
- Address: _________________________
- Phone Number: ____________________
Physician Information:
- Physician's Name: ________________
- Medical License Number: ___________
- Practice Name: ___________________
- Phone Number: ____________________
This order indicates that the patient does not wish to undergo cardiopulmonary resuscitation (CPR) or advanced life support if their heart stops or they stop breathing.
Reasons for DNR Order:
- _______________________________
- _______________________________
- _______________________________
This order must be signed by both the patient (or their legal representative) and the attending physician.
Signatures:
- Patient or Legal Representative: ________________ Date: ___________
- Attending Physician: ________________ Date: ___________
It is advisable to keep a copy of this document in the patient's medical records and to provide a copy to the designated healthcare providers.
For any questions or concerns, please consult a legal or medical professional.