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New Hampshire Do Not Resuscitate (DNR) Order Form

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New Hampshire Do Not Resuscitate (DNR) Order Form

Updated July 19, 2023

The New Hampshire do not resuscitate (DNR or DNAR) order form is a document used by a patient to record their wishes regarding resuscitation in the event of cardiac or respiratory arrest. This document will be printed on pink paper and put in their medical record. A DNR order is often issued to people who are at risk to enter into a vegetative state if they receive CPR or who are already in a coma. When a patient is moved to another facility or if their condition changes considerably, their DNR order should be reviewed to ensure that it is still necessary and in line with the patient’s wishes.

Laws – R.S.A. Chapter 137-J (see J:26 for form)

Required to Sign – Physician and patient (or health care agent).

How to Write

Step 1 – Download in PDF.

Step 2 – Provide the last name, first name, date of birth, and last four (4) digits of the patient’s SSN. Below that, if the patient wishes to issue a DNR order, mark the checkbox that indicates that this is the case. You must also supply the physician/ARNP’s name, signature, and the date, as well as any additional instructions regarding treatment of the patient.

Step 3 – In Section B, indicate “No” or “Yes” as to what end-of-life planning the patient has and list the relevant documents’ location. Next, supply the name, signature, date, address, and phone number for the patient or their representative (parent, authorized signatory, health care agent, or guardian). Please note that the form must be printed on bright pink paper.

Step 4 – If the Portable DNR Card has been filled out and given to the patient, select “Yes” to indicate that this is the case.

Step 5 – Fill out the Portable DNR Card by providing the name, address, phone number, and signature of the patient, physician, and (if applicable) the health care agent.