Florida Do Not Resuscitate Order Template
This Do Not Resuscitate (DNR) Order is prepared in accordance with Florida law, specifically Florida Statutes Section 401.45. It provides direction for healthcare providers when the person named below is experiencing a medical emergency.
Patient Information:
- Patient's Full Name: ____________________________
- Date of Birth: ____________________________
- Address: ____________________________
Florida Physician's Order:
The undersigned physician, after discussion with the patient or the patient's healthcare surrogate, has determined that the patient is in a terminal condition or is permanently unconscious. Therefore, this order for Do Not Resuscitate (DNR) is executed:
Physician's Name: ____________________________
Physician's Signature: ____________________________
Date: ____________________________
Patient/Surrogate Acknowledgment:
I acknowledge that I have discussed the implications of this Do Not Resuscitate Order with my physician. I understand that, in the event of a cardiac or respiratory arrest, resuscitation efforts will not be initiated.
Signature of Patient/Surrogate: ____________________________
Date: ____________________________
This DNR Order must be presented to healthcare providers to ensure its implementation. It is recommended that copies are kept in easily accessible locations.