Rhode Island Do Not Resuscitate Form

Information you will need

• What’s the patient’s last name?
• What’s the patient’s first name?
• What’s the patient’s date of birth?
• What's the date and time?
• What’s the patient’s gender?
• What are the patient’s CPR orders?
• What are the patient’s treatment orders?
• Does the patient want to be transferred to a hospital?
• What are the patient’s artificial hydration preferences?
• What are the patient’s artificial nutrition preferences?
• Does the patient have a health care proxy?
• Does the patient have a living will?
• Was the patient part of the discussion?
• Was the health care decision maker part of the discussion?
• Was the parent/guardian part of the discussion?
• Was the court appointed guardian part of the discussion?
• Was someone else part of the discussion?
• Who else was part of the discussion?
• What’s the health care provider’s phone number?
• What’s the health care provider’s Rhode Island license number?
• What’s their relationship to the patient?
• What's the name and address of the patient or decision maker?
• What's the outcome of the review?
• What’s the name of the individual who reviewed this form?

…and 5 more fields in the PDF.

Completed by the provider.