DNR form: Free template and how to complete it

Key takeaways

A DNR form is a legal medical order telling healthcare providers not to perform CPR if a patient’s heart or breathing stops.

Only physicians, and in some states nurse practitioners or physician assistants, can authorize a DNR order after the patient or surrogate consents.

DNR rules differ by state, so the witness, notarization, and EMS filing requirements that apply to you come from your own state statute.

The downloadable template covers physician information, the DNR request statement, duration, healthcare proxy details, witness signatures, an optional notary section, and a distribution checklist.

Practice management software like Pabau stores the signed order inside the patient record, so clinical staff can find it in seconds.

A do-not-resuscitate (DNR) form is one of the most consequential documents a practice handles. It records a patient’s decision to decline cardiopulmonary resuscitation if their heart or breathing stops. That decision carries legal weight in hospital and out-of-hospital settings alike.

The mechanics cause more trouble than the decision itself. Practices need to know who can sign the order, what their state requires, and where the signed copy has to go. Getting any of that wrong can mean a patient receives CPR they explicitly refused.

This guide covers what a DNR form is, who completes it, and how to fill one out correctly. It also shows how to fold the signed order into your patient care workflow with digital forms and a patient record management system.

What is a DNR form?

A do-not-resuscitate (DNR) form is a legal medical order. It instructs emergency responders and healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient’s heart stops or breathing ceases. The form records the patient’s informed wishes alongside the ordering physician’s clinical judgment. That combination is what makes it binding in most US healthcare settings.

A DNR order withholds CPR alone, and the rest of the treatment plan continues. If the patient’s condition worsens, clinicians still provide comfort care, medications, oxygen, and monitoring. Only the chest compressions and defibrillation of CPR are held back. Both clinical staff and families need to hear that stated plainly.

A valid out-of-hospital DNR form (sometimes shortened to OOH-DNR) tells Emergency Medical Services not to start CPR. This protects the patient’s autonomy before they reach a hospital. It also prevents resuscitation that contradicts their documented wishes.

Key elements of a valid order

• Patient identification and signature: confirms that the patient, or their surrogate if the patient lacks capacity, understands and consents to the order.
• Physician order and signature: the ordering clinician records the clinical rationale and authorizes the order with a signature and date.
• Consent declaration: written confirmation that the patient or surrogate received an explanation and consented without coercion.
• Witness and notarization: most states require one or two witnesses, and some require notarization, to show the order was signed without duress.
• Effective date and scope: when the order starts, whether it applies in hospital or out of hospital, and any conditions or time limits.

What’s included in the downloadable template

The template gives you the structure of a DNR order rather than a state-issued form. Here is what each section of the file covers.

• Physician information: the attending physician’s name and contact details.
• Statement of DNR request: an open section for the wording of the order and the clinical basis behind it.
• Duration of the DNR order: permanent or conditional, with space to specify the conditions or timeframe.
• Healthcare proxy or legal representative: name and contact details, where one applies.
• Witness signatures: two blocks, each with an attestation that the witness is not related to the patient or a beneficiary.
• Notary public (optional): a certification block for states and practices that require notarization.
• Copies and distribution: a checklist covering the patient, primary care physician, proxy, other providers, and EMS.
• Review and renewal: a note that the order is reviewed periodically as the patient’s condition and preferences change.
• Signatures: dated signature lines for the patient (or legal representative) and the attending physician.

The file deliberately leaves two things to you. It has no pre-set patient identification block, so add the patient’s name, date of birth, and record number yourself. It also carries no state-specific content, so check your state’s DNR statute for the witness, notarization, and EMS filing rules that apply.

Who can complete and sign the order?

In most US states, a licensed physician must sign the DNR order. State laws vary, and some states let nurse practitioners or physician assistants initiate one under specific supervision protocols.

The patient signs the form themselves if they have decision-making capacity, meaning they can understand the order and its consequences. If they cannot, a surrogate signs for them, such as a healthcare proxy or a court-appointed guardian. Which surrogate takes priority depends on the hierarchy in your state’s statute.

• Ordering physician or advanced practitioner: signs once the DNR matches the patient’s condition and stated wishes.
• Patient or legally authorized surrogate: signs to confirm understanding and consent.
• Witnesses, usually one or two: attest that the signature was given willingly. Many states bar the physician and family members from witnessing.
• Notary public, in some states: verifies the signatures and the document’s legal standing.

How to complete a DNR form, step by step

Completing a DNR form correctly is a shared job across clinical and administrative staff. Here is the workflow, from the first conversation to the filed document.

1. Hold the conversation. The physician meets the patient, or a surrogate if the patient lacks capacity, to discuss health, prognosis, and end-of-life values. This conversation must address what CPR involves, the likelihood of success given the patient’s condition, and what the order means for ongoing care. Document the discussion in the clinical note.
2. Write the physician order. If the patient or an authorized surrogate chooses a DNR, the physician writes the order in the medical record and on the form. The order notes the clinical basis and the date it takes effect.
3. Complete the form and take the patient signature. Fill in the patient information: full name, date of birth, and medical record number. The patient, or a surrogate with a copy of their legal authority, reads the consent language, then signs and dates the form.
4. Collect witness signatures. Two witnesses attest that the patient or surrogate signed knowingly and without pressure. Witnesses are usually staff members rather than family or the ordering physician. They print their names and addresses and add the date.
5. Arrange notarization if your state requires it. Some states require the form to be notarized, so check your state’s DNR statute. A notary public verifies the identity of the signers and the authenticity of the signatures.
6. Add the physician signature and date. The ordering physician signs and dates the form to finalize the order.
7. Store the form and share copies. File the original in the patient’s medical record, or scan it into your digital records system. For out-of-hospital validity, send copies to the patient, their emergency contact, and local EMS where the state requires it. Some states issue a DNR bracelet or wallet card, so give these to the patient where they apply.
8. Educate the patient. Make sure the patient and family understand that comfort care continues. They still receive medications, oxygen, pain management, and emotional support. The order withholds CPR alone, and only in cardiac or respiratory arrest.

A structured clinical documentation process keeps that sequence consistent between staff. Many practices use the digital forms in practice management software like Pabau to walk staff through the checklist. The same system pulls patient data through automatically and stores the signed file with the patient record.

Can a DNR order be revoked or changed?

Yes. A patient, or a surrogate with legal authority, can revoke a DNR order at any time. A patient may change their mind about CPR, and the care team has to respect that immediately. Revocation can be verbal or written, though writing it down prevents confusion later.

Document the revocation in the medical record with the date and time. Some states also let the patient destroy the form as an act of revocation. Either way, notify the medical team, the emergency contact, and any EMS service holding a copy.

Then remove the DNR flag from your patient management system, so no one honors an order that no longer stands.

DNR vs. POLST vs. advance directive vs. living will

Patients and families often confuse DNR orders with other end-of-life planning documents. Here is how the four differ.

The key difference: a DNR is a physician’s medical order. An advance directive and a living will are patient documents that guide the physician’s decisions.

A POLST is a broader set of orders that covers DNR scope plus other life-sustaining treatments. National POLST lists how each state runs its own program. Many facilities ask patients to complete an advance directive and a DNR form both, so intentions stay clear across settings.

Regulatory and state-specific requirements

DNR laws vary by state. Some states publish an official DNR form that must be used, while others accept a custom form that meets the statutory requirements. State departments of health, state medical boards, and state EMS authorities set those rules.

The federal Patient Self-Determination Act requires hospitals and long-term care facilities to tell patients about their right to make an advance directive. A DNR order falls under that right.

The Centers for Medicare and Medicaid Services expects facilities to honor valid DNR orders and document them clearly in the record. Requirements for witnesses, notarization, and EMS filing differ by state, so verify your statute before you finalize anything.

Practices that already manage HIPAA compliance should treat DNR forms the same way. Store them securely and limit access to authorized clinical staff. Any release outside the care team should be covered by a signed authorization for disclosure.

Where DNR orders come up most

DNR orders come up wherever end-of-life care is part of the conversation. Palliative care and hospice teams handle them daily. Oncology practices see them often, as does any practice treating advanced organ failure such as congestive heart failure.

Primary care practices raise the subject over a much longer relationship, often across several years. Geriatric practices meet it at transitions of care, when a patient’s independence changes.

Mental health practices meet these orders too, usually when treating older patients with advanced physical illness. Medical directors and nurse practitioners rely on a clear, accessible order to act quickly in an emergency.

Why careful documentation pays off

A clear, legally valid DNR protects the patient’s autonomy and the practice’s position at once. When the wishes are documented and every provider can see them, nothing is ambiguous in a crisis. The clinical team acts with confidence, and families can see the decision was respected.

A well-documented order also supports patient compliance with care planning. Patients feel heard when their preferences are written down, stored safely, and reviewed. It supports healthcare compliance standards too, and it lowers the risk of a dispute if a resuscitation decision is questioned later.

Fitting the signed order into your workflow

Practices use patient management software to hold the whole set of end-of-life documents in one place. Once the DNR is signed, scan or upload it into the patient’s digital record so that:

• Any clinician opening the record sees the DNR status and its scope, in hospital, out of hospital, or both.
• Alerts prompt staff to check the order at each visit, in case the patient’s wishes have changed.
• The form is flagged for review at annual check-ins and after any significant change in health.
• Administrative staff can report on which patients hold an active DNR order.
• The order can be referenced in the discharge summary when a patient transfers to another facility.

A comprehensive practice management system also shows which patients have no end-of-life documentation at all. That lets you open the advance care planning conversation early, before a crisis or a move into assisted living forces it.

How Pabau keeps signed DNR orders in the patient record

In many practices the signed DNR sits in a paper chart or a shared drive. Staff have to remember it exists, and hunting for it during an emergency costs time nobody has.

Pabau stores the completed form inside the client record, next to the appointment history and clinical notes. Any authorized clinician who opens that record sees the order and its scope straight away. You can also upload the signed PDF, note who received a copy, and set a reminder to revisit the order at the next visit.

The outcome is one place to check instead of three. Your team stops chasing paper, and a patient’s stated wishes are visible at the moment they matter.

Keep DNR orders in the patient record

Pabau’s digital forms and client records store signed DNR orders alongside appointments and clinical notes. Your staff can find the order in seconds, and reminders keep it under review.

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Conclusion

A DNR order only works if it is signed correctly and findable the moment it matters. The clinical conversation is the demanding part, but the filing is what usually fails the patient.

Use the template as a starting structure, then adapt it to your state’s statute and add your own patient identifiers. Store the signed copy in the patient record, hand out copies to everyone on the distribution list, and review the order at each visit.

Book a demo to see how Pabau stores signed DNR orders in the patient record and keeps them under review.

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Frequently asked questions