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Tennessee Do Not Resuscitate Form

Tennessee Do Not Resuscitate Form
Tennessee Do Not Resuscitate Form
PH-3338 (Rev. 7-96) RDA N/A
CPR
STATE OF TENNESSEE
EMERGENCY MEDICAL SERVICES
DO NOT RESUSCITATE (DNR)
ORDER
Patient’s Full Name
ATTENDING PHYSICIAN’S STATEMENT
I am the attending physician of the patient named above and direct medical personnel not initiate cardiopulmonary
resuscitation on this patient. I understand that I may revoke these directions at any time.
Date signature of Attending Physician
PRINTED NAME OF ATTENDING PHYSICIAN
THIS ORDER REMAINS IN EFFECT UNTIL THE DEATH OF THE
PATIENT OR THE DOCUMENT IS DESTROYED
PATIENT’S STATEMENT
I, the undersigned patient, or agent with a durable power of attorney for health care, direct that cardiopulmonary
resuscitation should not be initiated. I understand that I may revoke these directions at any time.
Signature of Witness Signature of Patient
Printed Name of Witness Printed Full Name of Patient
Date Signature of DPAH/C
Printed Full Name of Person Acting with durable
power of attorney for health care
THIS FORM WILL ACCOMPANY THE PATIENT DURING AMBULANCE TRANSPORT
A photostatic copy of the original, properly executed form may serve as a legal DNR order pursuant to Tennessee Code
Annotated § 68-140-602(1)
In the event of the patient’s death, the EMS agency on the scene shall obtain this form and it shall become part of the
EMS Medical Record.
Permission is hereby granted to reprint blank copies of this form for use by patients and physicians. Such copies must
include the complete and original text of both sides of the form with no additions or deletions.
Tennessee Do Not Resuscitate Form
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