Minnesota Do Not Resuscitate (DNR) Order FormMinnesota Do Not Resuscitate (DNR) Order Form
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HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROVIDERS AS NECESSARY FOR TREATMENT

MINNESOTA

Provider Orders for Life-Sustaining Treatment (POLST)
Follow these orders until orders change. These medical
orders are based on the patient’s current medical
condition and preferences. Any section not completed
does not invalidate the form and implies full treatment
for that section. With significant change of condition
new orders may need to be written. Patients should
always be treated with dignity and respect.

A

CHECK
ONE

LAST NAME

FIRST NAME

MIDDLE INITIAL

DATE OF BIRTH

PRIMARY MEDICAL CARE PROVIDER NAME

CARDIOPULMONARY RESUSCITATION (CPR)

PRIMARY MEDICAL CARE PROVIDER PHONE (WITH AREA CODE)

Patient has no pulse and is not breathing.

Attempt Resuscitation / CPR (Note: selecting this requires selecting “Full Treatment” in Section B).
Do Not Attempt Resuscitation / DNR (Allow Natural Death).
When not in cardiopulmonary arrest, follow orders in B.

B

CHECK
ONE
(NOTE
REQUIREMENTS