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OO TENS “Supplemental” Documentation Form for MINORS For Do-Not-Resuscitate (DNR) Orders For MOLST Program Medical Orders for Life-Sustaining Treatment Nit Actual orders showld he placed on the MOLST form, New Vork State Public Health Lave feavres capac to issuing a DNR order. The physician i responsibe for compli Bath the -MOLST and this documentation form, and fr obtaining the addtional congiatios signatures Where idiated. These forms must be placed inthe medical csord, This dacumentaton isnot reqiealif CPR order ix chosen Sept: Physician determination of lack of capaci have examined the patineidemt an hve medial eo fraranshavedterind that the patent resi ae Fh dena ave ine ably to understand and appreciate ee and consists ofa DNR order, including benefits and burdens of such an order ant each an informed esto Step2: Physic have examined the patient/resident and ‘medical certainty that: (chock ll itor) ‘The paienesident has terminal comiion by. The pticnresidetis permanently unconscious . Resuscitation would Remedial futile 4. Resusstaion veoh impose angsiaordinary burden on the patcntesdem in light ofthe pation resident's neal condition and the especie outcome of resuscitation ity for cardiopulmonary resuscitatio ine medical record, and have determined toa reasonable degree of Step 3: Notification of other or non-custodial parent: (check one) [2 1 do ot hayereason lOblive that hee is another parent ora non-custodial paren ‘Ts. 1 havereasonfo, believe that there is anther parent, ofa non-custodial parent ‘Ressonsbl cffos have been made a attemp! wo deemine ithat pact has mintaned substantial and continuous h he paticnresidon. and iso, diligent efforts have been made to nol that parent of he dscision and succes! unsuccessful Describe efoMUeonnct: Note: If the other parent opposes entry of the DNR order, the matter must be submitted to dispute mediation and the order may not be entered and must be revoked pending resolut "HIPAA Pers Deco of OUST fs OierHeah Cae Ptesrank & Besa Ragny SRA ETRE ‘Step: Additional Requirements for residents from facilities operated or licensed by OMH ‘or OMRDD: (complet only ifsplcabl) "The director ofthe following acl rom which the patien/esident wa ransferred, has hea noi of the decision 0 enter the DNR oer. [Name of foil notifie: Print name of person nif: Step'S: Parent’s/Legal Guardian’s Consent: As pr Public Health Law s2147(00), a parebaay goes verbal consent in the pronnce of 2 witene one of whom met be MD fated with de holo bigs patiet fs being ‘weated. Parent defined o beth person having custody ofthe minor. In the ease of diverceseparao he cst dia pant would beth one convo ow DNRorder na deiermined bythe ert as part ofthe dveccepar iirc, As the parent or legal guardian of (pevientresiden ime Bastia Dr To write a DNR ord for tgponent resident. [under ai this mars tha cardiopuinonaryresuciaion wT be withheld if his her heart stops Beelng andor he she stops breathing Parentguardian signature Date 1 eer tar the person whose sananre opmears above Ae cnd dates form i my presence ‘Witness signature: Date: Print witness name: StEp16: Patient/Resident Consent: (ONLY ifthe patientiresident has capacity — see Step 1 above) Teomsent to entry ofthe DNR Order ex on the MOLST Form Patientiresident signature: Si@PI7!_ Physician Certificatidmand Signature: Teerfy that [have examinalthe pat resident and hisher medical record, and that Ihave reviewed and ‘competed Steps |-6 en this document, supporting my writing a do-notresusetate order on the MOLST Form in thigatentesdent’s meal record. Physician Senatare Pri Name ‘Step'8: Concurring physician certification and signature: Teen that examined the patinresident and hisher mesial cord and have reviewed Steps & 2in his form etcrminaton of lack of decision-making capacity and certification of lack of wility of cardiopulmonary resuscitation, supporting, with ateasonabe degree of medical certainty, the ph icin writing a do-nt-resurcitat order onthe MOLST For inthis pacatesients medial record ‘Concureing Pica Sinan vce te gt HOLST coment th PULS97 5