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Missouri Do Not Resuscitate (DNR) Order Form

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The Missouri do not resuscitate (DNR) order form is a document that a patient fills out if they do not want life-saving procedures to be implemented in the event that they have a cardiac or respiratory arrest. There are a variety of reasons that an individual may wish to issue a DNR order, the leading reason being that the subject is already in critical condition and near death. The DNR order form, once completed, will be placed as the first page of the patient’s medical record in order to notify medical personnel of the patient’s wishes. If the patient is transferred from one facility to another, the form will be sent to the second facility and remains in their medical record.

Laws – § 190.603

Required to Sign – Physician and patient (or an authorized representative) must sign.

How to Write

Step 1 – Download the Missouri DNR Order form in Adobe PDF format.

Step 2 – Write your name in the blank space in the paragraph at the top of the page.

Step 3 – Next, enter your name, the date, and provide your signature in the indicated fields.

Step 4 – The “Revocation Provision” will only be filled out in the event that the patient or their representative wishes to revoke the DNR Order. Leave this section blank.

Step 5 – At the bottom of the page, the attending physician must provide their signature, the date, their printed name, their license number, their telephone number, their address, and the name of their facility/agency.

Step 6 – You may also wish to download and fill out the DNR Identification Card, this card can be placed in an identifying bracelet, necklace, or somewhere on the patient’s/your person in order to alert medical staff of the DNR Order. On the first side of the card, you must provide the patient’s full name, the physician’s signature and printed name. Below that, enter the attending physician’s address, phone number, and the date.

Step 7 – On the second side of the card, the patient (or representative) must provide their name, their signature, and the date. Once completed, this card may be cut out and folded or attached so that both sides are facing out.


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