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South Dakota Do Not Resuscitate (DNR) Order Form

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The South Dakota do not resuscitate (DNR) order form instructs emergency medical personnel to withhold the administration of cardiopulmonary resuscitation (CPR) to a patient whose heart or breathing has stopped. This type of medical order is often requested by individuals who would prefer to die naturally and avoid the suffering of resuscitative treatments. The DNR form or bracelet must be present at the time of an emergency or else the attending medical staff will be required to resuscitate the individual. Therefore, the DNR order/bracelet should be kept close to the individual and made easily accessible.

Laws – ARSD 44:05:06 and SDCL 34-12F

Required to Sign – MD/PA/NP, and patient.

How to Write

Step 1 – Download the South Dakota DNR order form in Adobe PDF.

Step 2 – Begin filling in the form by entering the patient’s name, phone number, address, city, state, and zip code.

Step 3 – Continue providing the patient’s information by entering their date of birth, gender, eye color, hair color, race/ethnic background, and the name of their hospice program (if any).

Step 4 – Next, the authorized health care professional’s information must be provided. Enter the individual’s name, address, and phone number.

Step 5 – Below the “DO NOT RESUSCITATE” heading, the patient must provide their signature. After signing, the date must be entered in the space on the right.

Step 6 – Finally, the physician/PA/NP must provide their signature followed by the date of execution.


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