Tennessee Do Not Resuscitate Form

Information you will need

• What’s the patient’s last name?
• What’s the patient’s first name and middle initial?
• What's the patient's date of birth?
• What are the patient’s CPR orders?
• What are the patient’s treatment orders?
• What are the patient's other instructions?
• What are the patients other artificial nutrition instructions?
• Was the patient/resident part of the discussion?
• Was the health care agent part of the discussion?
• Was the court appointed guardian part of the discussion?
• Was the health care surrogate part of the discussion?
• Was the parent of a minor part of the discussion?
• Was someone else part of the discussion?
• Who else was part of the discussion?
• What's the unlisted basis for these orders?
• What's their relationship to the patient?
• What's the agent/surrogate's name?
• What's the agent/surrogate's relationship to the patient?
• What's the agent/surrogate's phone number?
• What's the preparer's title?
• What’s the health care professional's phone number?
• What are the patient’s artificial nutrition preferences?
• What's the name of the patient, parent, guardian, or health care representative?
• What's the health care professional's name?

…and 7 more fields in the PDF.

Completed by the agent.