Louisiana Do Not Resuscitate Form

Information you will need

• What’s the patient’s first name?
• What’s the patient’s DOB?
• What are the patient’s CPR orders?
• What are the patient’s treatment orders?
• What’s the patient’s first/middle name?
• What’s the patient’s condition?
• What are the care goals?
• What are the patient’s additional orders?
• What are the patient’s nutrition preferences?
• Did the patient choose to implement this form?
• Did the patient’s representative choose to implement this form?
• Does the patient’s advance directive indicate treatment preferences?
• Would resuscitation be non beneficial?
• When did the patient create their advance directive?
• Was a health care agent appointed?
• What’s the physician’s name?
• What’s the physician’s phone number?
• What’s the signing party’s name?
• What’s the representative’s address? (if applicable)
• What’s the representative’s phone number? (if applicable)
• What’s the patient’s last name?
• What’s the patient’s middle name?
• Does the patient have an advance directive?
• What’s the patient’s medical record number? (optional)

…and 9 more fields in the PDF.

Completed by the provider.