North Carolina Do Not Resuscitate (DNR) Order FormNorth Carolina Do Not Resuscitate (DNR) Order Form
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HIPAA PERMITS DISCLOSURE OF MOST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY

Medical Orders

Patient’s Last Name:

Effective Date of Form:

Patient’s First Name, Middle Initial:

Patient’s Date of Birth:

for Scope of Treatment (MOST)
This is a Physician Order Sheet based on the patient’s medical
condition and wishes. Any section not completed indicates full
treatment for that section. When the need occurs, first follow
these orders, then contact physician.

Section
A
Check One
Box Only

Section
B
Check One
Box Only

CARDIOPULMONARY RESUSCITATION (CPR): Patient has no pulse and is not breathing.
Attempt Resuscitation (CPR)
Do Not Attempt Resuscitation (DNR/no CPR)
When not in cardiopulmonary arrest, follow orders in B, C, and D.

MEDICAL INTERVENTIONS: Patient has pulse and/or is breathing.
Full Scope of Treatment: Use intubation, advanced airway interventions, mechanical ventilation, cardioversion as
indicated, medical treatment, IV fluids, etc.; also provide comfort measures. Tr