Ohio Do Not Resuscitate (DNR) Order Form

Create a high quality document online now!

Updated March 28, 2022

An Ohio Do Not Resuscitate (DNR) Order Form tells emergency medical service providers and other health care professionals that a patient does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. A patient with a DNR order in place will receive general care to alleviate pain such as oxygen and pain medication, though no life-saving or life-prolonging treatments will be administered. The DNR order may be executed by the patient, by an authorized representative acting on the patient’s behalf, *or under the conditions of the patient’s living will.

*Two (2) physicians must certify the individual as being in a permanently unconscious state, terminally ill, or both.

Laws ORC – Chapter 2133

Required to Sign – Physician.

How to Write

Download: Adobe PDF

Step 1 – Acquire The PDF Ohio Do Not Resuscitate (DNR) Order Form Template

The Ohio Doe Not Resuscitate (DNR) Order is a “PDF” template that is viewable through the sample image and downloadable through the “PDF” button (or “Adobe PDF” link) presented on this page.

Step 2 – Identify The Ohio Patient Behind The Ohio Order

The Ohio Patient issuing this order must be presented by name and birthday at the onset as the Declarant behind this form. The first row, containing the label “Patient Name” and the label “Patient Birth Date” should be populated with these items in the respective space provided below each label. 

 

Step 3 – Present The Ohio Patient’s Signature Of Execution

This order’s authenticity will be clearer to attending Ohio Medical Staff if it is signed by the Patient originating it. Thus, while the second row is optional, it is strongly recommended that the Patient sign his or her name beneath the label “Optional Patient Or Authorized Representative’s Signature.” If the Issuer of this Ohio form is the Health Care Agent of the Patient and the criteria for his or her power of representation has been met, then the Health Care Agent may sign this row in lieu of the Patient. 

 

Step 4 – Obtain The Physician’s Information

This document requires that it be issued under the oversight of an Ohio Physician. This must be evident to any Reviewer. To this end, the third row shall seek the “Printed Name Of Physician, APRN, Or PA” attending this form. Notice that while it is preferred that a Physician’s name appears here, the attending Advanced Practice Registered Nurse or Physician’s Assistant responsible for the Ohio Patient’s care (or paperwork) may be named as its Preparer. 

 

Step 5 – Produce The Physician’s Approval to This Form

The Physician, Advanced Practice Registered Nurse, or Physician’s Assistant named as the Preparer must sign his or her name under the label “Required Signature Of Physician, APRN Or PA” After the signing, the Physician APRN, or PA responsible for this DNR must dispense his or her telephone number to the adjacent box labeled “Phone.”While the Advanced Practice Registered Nurse or Physician’s Assistant working under the Physician can complete this form the attending Physician must be named. Thus, if this Ohio document was completed by an Advance Practice Registered Nurse Or Physician’s Assistance then the full name of the Supervising Physician along with that “Physicians’ NPI, DEA, Or Ohio Medical License Number” must be furnished to the space corresponding to the words “Required For APRN Or PA.” 

 

Step 6 – Indicate The DNR Preferences Of The Ohio Issuer

 The Ohio Declarant (or Patient) has the option to define the level of care he or she wishes to receive when a DNR becomes a subject that must be addressed. If the Ohio Patient wishes the Medical Staff attending to understand that he or she approves of every treatment available until he or she suffers a cardiac arrest or respiratory arrest, then the checkbox statement labeled “DNR Comfort Care – Arrest” must be selected.  If the Patient wishes Medical Staff to institute the Ohio “DNR Protocol” then the “DNR Comfort Care” checkbox statement must have its corresponding checkbox selected. The area directly beneath this choice will summarize what the Patient may still expect in terms of care while at the same time solidify that Ohio Medical Staff will not engage CPR when needed, administer medical treatment aimed at restarting the “Heart Or Breathing,” physically clear airways when necessary, de-fibrillate or initial cardiac pacing and continuous cardiac monitoring.