Washington Do Not Resuscitate Order
This document serves as a Do Not Resuscitate (DNR) order in accordance with the laws of the state of Washington.
Patient Information:
- Patient's Name: ________________________
- Date of Birth: ________________________
- Medical Record Number: ________________________
Health Care Provider Information:
- Provider's Name: ________________________
- Provider's Signature: ________________________
- Date: ________________________
Patient/Legal Representative Information:
- Name: ________________________
- Relationship to Patient: ________________________
- Signature: ________________________
- Date: ________________________
This order indicates that the patient does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. It must be respected by all medical personnel.
Witness Information:
- Witness Name: ________________________
- Witness Signature: ________________________
- Date: ________________________
It is important that this DNR order is clearly displayed in the patient’s medical records and is accessible to emergency response teams.
For questions regarding this order, please consult a healthcare attorney or a qualified health care professional.