Transcription of DO-NOT-RESUSCITATE (DNR)/PRACTITIONER ORDERS ST L O ...
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DO-NOT-RESUSCITATE (DNR)/PRACTITIONER ORDERS ST L O ...
DO-NOT-RESUSCITATE (DNR)/PRACTITIONER ORDERSFOR LIFE-SUSTAINING TREATMENT (POLST) FORMS tate of IllinoisIllinois department of public health For patients, use of this form is completely these ORDERS until changed. These medical ordersare based on the patient s medical condition and prefer-ences. Any section not completed does not invalidate theform and implies initiating all treatment for that significant change of condition new ORDERS mayneed to be Last NamePatient First NameMIDate of Birth (mm/dd/yy)Gender qM qFAddress (street/city/state/ZIPcode)ACheckOneCARD IOPULMONARY RESUSCITATION(CPR) If patient has no pulse and is not Resuscitation/CPRqDo Not Attempt Resuscitation/DNR(Selecting CPR means Full Treatmentin Section B is selected)BCheckOne(optional)MEDICAL INTERVENTIONSIf patient is found with a pulse and/or is Treatment: Primary goal of sustaining life by medically indicated means.
DO-NOT-RESUSCITATE (DNR)/PRACTITIONER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) FORM State of Illinois Illinois Department of Public Health P For patients, use of this form is completely voluntary.
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