Blank Do Not Resuscitate Order Template for Iowa

Iowa Do Not Resuscitate (DNR) Order Template

This document serves as a Do Not Resuscitate (DNR) Order in accordance with the laws of the State of Iowa, specifically referencing the Iowa Code Chapter 144A.7A. It is designed to inform healthcare providers of the patient's decision to forego resuscitation attempts in the event of cardiac or respiratory arrest. Completion of this form should be done with thorough understanding and consideration of its implications, and it is recommended to be completed with a healthcare provider's guidance.

Please enter the required information in the spaces provided:

• Patient's Full Name: ___________________________________________________
• Patient's Date of Birth: ________________________
• Patient's Address: ______________________________________________________
• Primary Physician (if applicable): ________________________________________
• Medical Record Number (if applicable): ____________________________________

Iowa DNR Order Conditions:

1. The decision to resuscitate should not be initiated if the patient's heart stops beating or if the patient stops breathing.
2. This order is valid throughout the State of Iowa and should be presented to healthcare providers to be executed according to the patient's wishes.
3. Alteration, forgery, or misuse of this document is subject to legal penalties under applicable Iowa laws.
4. This order can be revoked by the patient at any time by destroying the document, by oral statement, or by creating a new directive that conflicts with this order.

In witness whereof, the following parties have affixed their signatures:

Patient's Signature: ______________________________________ Date: ___________

If the patient is unable to sign, a representative who is authorized to make healthcare decisions on behalf of the patient may sign below:

Representative's Signature: __________________________________ Date: ___________

Relationship to Patient: ____________________________________________________

Witness Signature: __________________________________________ Date: ___________

Witness Printed Name: ______________________________________________________

This document was prepared on the basis of the patient's current medical condition and in consultation with a licensed healthcare provider:

Healthcare Provider's Signature: ______________________________ Date: ___________

Printed Name: ________________________________________________

License Number: _______________________________________________

Note: Upon completion, multiple copies of this document should be made and kept in easily accessible places. Copies should be provided to the patient's primary healthcare provider, family members, or any designated healthcare proxy. It is also recommended to carry a copy on one's person at all times.