Medical Directive - DNR - Preparation Worksheet

FLORIDA DNRO REQUEST AND PREPARATION WORKSHEET

Not Form DH 1896 or a Medical Order

CRITICAL NOTICE: Signing this worksheet does not create a Florida Do Not Resuscitate Order (DNRO) and does not direct an EMT or paramedic to withhold resuscitation. Use current Florida Department of Health Form DH 1896, Revised 02/2024, with the required signatures and a full-page yellow background or yellow paper.

Florida's DNRO is a specific, limited direction to Florida EMTs and paramedics for cardiac or respiratory arrest. It is different from a facility DNR, advance directive, living will, or POLST.

1. PATIENT INFORMATION

2. INFORMED REQUEST

The official form records the patient's informed direction that CPR be withheld or withdrawn in the event of cardiac or respiratory arrest. CPR on DH 1896 includes artificial ventilation, cardiac compression, endotracheal intubation, and defibrillation.

☐ Patient's goals and treatment preferences discussed

☐ Consequences of withholding or withdrawing CPR explained

☐ Questions answered by the treating provider

☐ Decision made voluntarily

Florida's DNRO statute and current form do not require a terminal diagnosis, a stated prognosis, or a finding that CPR offers no reasonable expectation of recovery.

3. PATIENT OR AUTHORIZED PERSON

Signer: ☐ Competent patient ☐ Authorized person

Authorized person's name: [________________________________]

Authority selected on DH 1896:

☐ Health care surrogate

☐ Health care proxy

☐ Minor patient's principal

☐ Guardian expressly authorized to make health care decisions

☐ Agent under a power of attorney expressly authorized to make health care decisions

Supporting document and medical-record location: [________________________________]

☐ Patient competence or incapacity status confirmed

☐ Authorized person's identity and current authority verified

☐ Correct authority category marked on the official form

Patient or authorized person signature on this worksheet: [________________________________]

Date: [__/__/____]

This worksheet signature is not the signature required on DH 1896.

4. AUTHORIZED HEALTH CARE PROVIDER

Provider name: [________________________________]

Provider category:

☐ Florida-licensed physician

☐ Florida-licensed osteopathic physician

☐ Florida advanced practice registered nurse registered for autonomous practice

☐ Florida-licensed physician assistant authorized by law

License number: [________________________________]

Emergency telephone number: [________________________________]

☐ Provider confirmed authority to sign DH 1896

☐ Provider reviewed the patient's informed direction

☐ Provider completed the health care provider statement on the official form

Provider signature on this worksheet: [________________________________] Date: [__/__/____]

Fla. Stat. § 401.45(3) expressly addresses physician and physician-assistant orders. Fla. Stat. § 464.0123(3)(a)5 and the current rule and form also authorize an APRN registered for autonomous practice.

5. DH 1896 VALIDITY CHECKLIST

☐ Current official Form DH 1896, Revised 02/2024, used

☐ Entire full-size form has a yellow background or is printed on yellow paper

☐ Patient's full legal name and date of birth entered

☐ Patient or authorized person signed and dated

☐ Authorized person's printed name and authority completed, if applicable

☐ Authorized provider's printed name and license number entered

☐ Authorized provider signed and dated

☐ Emergency provider telephone number entered

☐ Printed wording and signatures are legible

The Florida Department of Health states that the DNRO does not require witnesses or notarization. The patient or authorized person should sign it at the same time as the authorized health care provider.

6. YELLOW COPIES AND DNRO DEVICE

Copies are valid only when they accurately reproduce the signatures, remain legible, and have a full-page yellow background or are printed on any shade of yellow paper.

☐ Yellow full-size original or copy kept readily accessible

☐ Yellow copy placed in the medical record, if appropriate

☐ Yellow copy provided to relevant provider, facility, hospice, family member, or caregiver

☐ Yellow copy placed in a noticeable location, such as on the refrigerator, if appropriate

The bottom of the current form contains a reduced-size duplicate that may be cut out, folded, laminated, carried with photographic identification, or worn or attached as described by the Department. The full-size DNRO remains valid if the device is not completed or is removed.

☐ Reduced-size DNRO device completed with both required signatures

☐ Device wording and signatures remain legible

☐ Device reproduced on yellow paper

☐ Device carried with identification or otherwise kept with the patient

Use of a standardized DNRO identification device is voluntary under Fla. Stat. § 401.45(3)(c).

7. EMS AND FACILITY USE

Present the yellow DNRO or valid yellow DNRO device to the Florida EMT or paramedic when emergency personnel arrive. The EMT or paramedic must keep the DNRO with the patient during transport.

Call 911 when emergency assistance is needed even if the patient has a DNRO. Florida Health states that EMS can provide comfort care, caregiver support, and transport without initiating prohibited resuscitation.

Hospitals, health care facilities, and hospices may honor DH 1896, but the Department's DNRO is specifically directed to EMTs and paramedics and the Department does not regulate facility DNR forms through this program. Confirm facility-specific orders and policies separately.

The Florida DNRO is directed to Florida-certified EMTs and paramedics. Verify the law of any other state before travel; do not assume interstate recognition.

8. REVOCATION AND DURATION

Florida Health states that a competent patient may revoke a DNRO by:

• orally or in writing expressing a contrary intent;
• physically destroying it;
• not presenting it to EMTs or paramedics; or
• signing an order from an authorized provider directing resuscitation.

If revoking, notify every provider, hospital, facility, hospice, caregiver, family member, and other person who has a copy, and address every yellow copy and DNRO device.

Date and method of revocation: [________________________________]

Persons and organizations notified: [________________________________]

Record update and copy/device disposition: [________________________________]

For a patient who is not competent, obtain immediate clinical and legal guidance about the authorized decision-maker and applicable records rather than assuming this worksheet creates revocation authority.

A properly completed DNRO does not expire, but it should be reviewed when treatment preferences, authority, provider information, or the official form changes.

9. COMFORT CARE AND SCOPE

The DNRO addresses withholding or withdrawing CPR upon cardiac or respiratory arrest. It is not a direction to withhold every treatment, nutrition, hydration, medication, or transport.

Florida Health identifies oxygen administration, hemorrhage control, pain management, caregiver support, and transport among the assistance EMS may provide. Use separate lawful orders and advance-care documents for treatment choices outside the DNRO's limited scope.

10. LIABILITY AND PRIVATE TERMS

Fla. Stat. § 401.45(3)(b) provides defined protections to specified licensees and professionals for withholding or withdrawing resuscitation pursuant to the statute and Department rules. Do not replace that statutory framework with private indemnity, release, liability-cap, default, fee-shifting, forum-selection, force-majeure, or enforcement clauses in the medical order.

11. OFFICIAL SOURCES

• Fla. Stat. § 401.45 — https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0401/Sections/0401.45.html
• Fla. Stat. § 464.0123 — https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0400-0499/0464/Sections/0464.0123.html
• Fla. Stat. § 765.101 — https://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0700-0799/0765/Sections/0765.101.html
• Fla. Admin. Code r. 64J-2.018 — https://www.flrules.org/gateway/RuleNo.asp?title=Trauma&ID=64J-2.018
• Florida Department of Health DNRO guidance — https://www.floridahealth.gov/about-us/resources/do-not-resuscitate-order/
• Form DH 1896, Revised 02/2024 — https://www.floridahealth.gov/wp-content/uploads/2025/08/dnro.pdf

Verify the current statute, rule, DH 1896 revision, signer credentials, representative authority, and EMS or facility protocol before relying on any order.