Nebraska Do Not Resuscitate Form

Information you will need

• What’s the patient’s DOB?
• What’s the physician's name?
• Does the patient understand what "do not intubate" means?
• Does the patient understand what "do not resuscitate" means?
• What’s the patient’s address?
• What’s the agency's name?
• Was the physician consulted via telephone?
• Is this form being submitted to the patient's file?
• Is a copy distributed to the patient’s home health or hospice agency?
• Is a copy distributed to the patient's attending physician?
• Is a copy distributed to the patient's home?
• What’s the patient’s name?

The form includes 1 signature line, a witness section.