Hawaii Do Not Resuscitate Form

Information you will need

• What’s the patient’s last name?
• What are the patient’s CPR orders?
• What are the patient’s treatment orders?
• What’s the patient’s DOB?
• What’s the provider’s phone number?
• What’s the provider’s name?
• What’s the provider’s license number?
• What’s the patient’s name?
• Who’s the patient’s emergency contact?
• What’s the patient’s first/middle name?
• What’s the completion date?
• What are the patient’s additional orders?
• What are the patient’s nutrition preferences?
• What’s the goal of the trial period?
• What are the patient’s additional nutrition orders?
• With whom was this POLST form discussed?
• What’s the relationship?
• What’s the representative’s title?
• What’s the signing party’s name?
• What’s the patient’s medical condition?
• What’s the patient’s gender?
• What’s the emergency contact’s relationship?
• What’s the emergency contact’s phone number?
• What’s the preparer’s title?

…and 5 more fields in the PDF.

Completed by the provider and the agent.