West Virginia Do Not Resuscitate (DNR) Order Form – Sample OnlyWest Virginia Do Not Resuscitate (DNR) Order Form – Sample Only
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HIPAA PERMITS DISCLOSURE OF POST TO OTHER HEALTH CARE PROFESSIONALS AS NECESSARY

West Virginia Physician Orders

Last Name

for Scope of Treatment (POST)

First

Mailing Address

By state law, these medical orders must be followed until changed. Any
section not completed indicates full treatment for that section.

City/State/Zip

REVISE ADVANCE DIRECTIVES AS NEEDED
FOR CONSISTENCY WITH POST ORDERS.

Date of Birth (mm/dd/yyyy)

Last 4 SSN

M

A
B

MEDICAL INTERVENTIONS: Person has pulse and is breathing.

Attempt Resuscitation/CPR

F

When not in cardiopulmonary arrest,
follow orders in B, C, and D.

Do Not Attempt Resuscitation/DNR

Comfort Measures Treat with dignity and respect. Keep clean, warm, and dry.
Use medications by any route, positioning, wound care and other measures to relieve pain and suffering and promote comfort. Use oxygen,
suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment.
Transfer only