Legal Do Not Resuscitate Order Template for New Jersey

New Jersey Do Not Resuscitate (DNR) Order Template

This Do Not Resuscitate (DNR) Order is in accordance with the New Jersey Practitioner Orders for Life-Sustaining Treatment Act (POLST). It is a directive for health care providers regarding the administration of life-sustaining treatments, including cardiopulmonary resuscitation (CPR), to the undersigned patient. This document is legally binding in New Jersey.

Patient Information

• Name: ___________________________________________________
• Date of Birth: ___________________________________________
• Address: _________________________________________________
• City, State, Zip Code: ____________________________________
• Phone Number: ___________________________________________
• Health Insurance Information (if applicable): _______________

Medical Information

• Primary Diagnosis: ________________________________________
• Allergies (if any): ________________________________________
• Primary Care Physician: ___________________________________
• Physician Phone Number: ___________________________________

DNR Order

I, ____________________________ (patient or legally authorized individual), hereby direct that no cardiopulmonary resuscitation (CPR) be administered to me by health care providers, including but not limited to hospital staff, emergency medical services, and other health care facilities and personnel. This order is to remain in effect until revoked by me or my legally authorized representative.

Signature

• Patient/Legally Authorized Representative Signature: _____________________________
• Date: _________________________________________________________________________

Physician Information and Signature

• Physician Name: ____________________________________________
• License Number: ____________________________________________
• Address: ___________________________________________________
• Phone Number: ______________________________________________
• Signature: _________________________________________________
• Date: ______________________________________________________

This Do Not Resuscitate Order complies with New Jersey state laws and regulations. It is recommended that this document be placed in an easily accessible location and that copies be provided to the patient's physician, hospital, and/or health care proxy.

Note: It is important to discuss this document and your wishes with your family, health care proxy, and physician. Completing this form does not prevent you from receiving other forms of medical care to provide comfort or alleviate pain.