Wyoming Do Not Resuscitate (DNR) Order FormWyoming Do Not Resuscitate (DNR) Order Form
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WyoPOLST
Providers Orders for Life Sustaining Treatment
HIPAA PERMITS DISCLOSURE TO HEALTHCARE PROFESSIONALS AS NECESSARY FOR TREATMENT
Last / First / Middle Name (Place ID Sticker Here if Applicable):
FIRST follow these orders, THEN contact the Physician, PA,
or APRN. This is a Provider Order Sheet based on the
person’s current medical condition and wishes. Any section
not completed implies full treatment for that section. Every
patient shall be treated with dignity and respect.

Date of Birth:

Last 4 SSN:

Gender:

____/_____/_____

___ ___ ___ ___

M /

F

CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.

A
Check
One

☐ CPR / Attempt Resuscitation

☐ DNR / Do Not Attempt Resuscitation (Allow Natural Death)

When NOT in cardiopulmonary arrest, follow orders in B and C
MEDICAL INTERVENTIONS: Person has pulse and/or is breathing.

B
Check
One

☐ FULL TREATMENT: Use intubation, advanced airway interventions, mechanical ventilation and
defibrillation/cardio