Ohio Do Not Resuscitate Order (DNR)
This Do Not Resuscitate Order (DNR) is executed in accordance with Ohio Revised Code § 2133.21 - § 2133.27. It expresses the wishes of the individual regarding resuscitation efforts in the event of a medical emergency.
Patient Information:
- Patient Name: ______________________________
- Date of Birth: ______________________________
- Address: ______________________________
- Phone Number: ______________________________
Physician Information:
- Physician Name: ______________________________
- Medical License Number: ______________________________
- Contact Information: ______________________________
Order Statement:
I, the undersigned patient, hereby request that in the event of a medical emergency where I am unable to communicate my wishes, no resuscitation efforts be made to revive me. This includes, but is not limited to, the use of chest compressions, artificial ventilation, and defibrillation.
Signature: ______________________________
Date: ______________________________
Witness Information:
- Witness Name: ______________________________
- Witness Signature: ______________________________
- Date: ______________________________
This order will remain in effect until revoked by the patient or by a physician. It is recommended to keep a copy of this order in an easily accessible location.