Maryland Do Not Resuscitate (DNR) Order FormMaryland Do Not Resuscitate (DNR) Order FormMaryland Do Not Resuscitate (DNR) Order Form
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MM 3 2013

Page 1 of 2

Maryland Medical Orders for Life-Sustaining Treatment (MOLST)
Patient’s Last Name, First, Middle Initial

Date of Birth

□ Male □ Female

This form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other
life-sustaining treatment options for a specific patient. It is valid in all health care facilities and programs throughout Maryland. This order form shall be kept
with other active medical orders in the patient’s medical record. The physician, nurse practitioner (NP), or physician assistant (PA) must accurately and legibly
complete the form and then sign and date it. The physician, NP, or PA shall select only 1 choice in Section 1 and only 1 choice in any of the other Sections
that apply to this patient. If any of Sections 2-9 do not apply, leave them blank. A copy or the original of every completed MOLST form must be given to the
patient or authorized decision maker within 48 ho