DNR form not filled out completely

Nurses General Nursing

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Hey guys I have a really important question to ask. I just graduated this may and currently working in a nursing home. I have one resident whom just coded today.

Upon arriving on shift, my unit manager told me that the patient is still full-code and not DNR. The DNR out-of-hospital order form is still haven't been filled out by the doctor, hospice, and the nephew (the responsible party of the resident).

While doing rounds and preparing to put on wound care dressing on this resident I saw that she was having trouble breathing and using her accessory muscles. I immediately took her vitals and Sp02. The Vitals were BP= 89/53 Pulse= 116 Respirations= 27 and Temp 97.4. Her Sp02 was 85% and steadily declining. I called respiratory right away to give her some oxygen which her sP02 increased to 79%.

I had to call 911 to come pick her up.

The question is I saw in her chart that the doctor did put down DNR and sign it in one of those receipt attachment form. However, it wasn't an official out-of-hospital DNR order form. I called the director of nursing and she told me the patient is DNR. I rush to the patient's chart and pull out that particular DNR form to show to the EMS people. They told me that form isn't valid because its one of those tear off form. It has to be an official out-of-hospital DNR form for her to be DNR. They took her to the hospital.

I'm really worried because 1) there was a DNR order from the doctor. 2) The doctor nor the nephew has officially sign on the out-of-hospital DNR order form.

I'm stuck between which one to follow. I'm really stress out right now. I had to stay back 4 hours to do paperwork and check if everything was correct. I did saw in the chart that her last advance directive flowsheet was done on 10/19/11 which was 2 years ago. That one still listed her as full-code and not DNR.

Thank you guys for the advice. It was just a whole bunch of mess and stress for me. The whole discreprencancy of the assistant of nursing telling me she is DNR then the nurse that takes care of the paperwork telling me she is still consider full code until further signatures to be completed. It was an emergency case so I didn't have time to run and look over the chart over and over again. I had look over it a few hours prior to make sure she was still full code.

I was just confused because the doctor did sign his name and put DNR under an order. However, he wrote it in one of those receipts where you tear off form. It wasn't an actual out-of-hospital DNR order form. The last DNR flowsheet that was under advanced directives was way back in 10/19/2011 and it still listed (I want CPR done) checked with the nephew (the patient's nephew) signature. So the place where I work at didn't update the files. It was just a whole lot of stress. I barely got any sleep worrying that I might get in trouble.

Specializes in Emergency Department.

To me, it sounds like there was some question as to whether the patient was DNR or not. Whenever there's a question about status, EMS is generally required treat the situation as if the patient is Full Code. In the OP's case, since the DNR order wasn't written on a specifically recognized form, the patient would be considered Full Code. Depending upon facility policy, that DNR order that was written in a non-standard way might not be recognized officially by the facility either. Where I live, if the Physician has a signed DNR order in the medical record, it's considered (usually) to be a valid DNR order. Some places require that only specific forms are recognized. In those instances, your facility may consider the patient a DNR but without those forms, the patient will be considered Full Code by EMS.

Often the form or order (or a copy of it) must be sent with EMS in order for that order to be followed during transport. That order also has to have patient demographics on it to identify that particular patient, just as if it was a medication, otherwise it would be considered an invalid order for purposes of transport.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thank you guys for the advice. It was just a whole bunch of mess and stress for me. The whole discrepancy of the assistant of nursing telling me she is DNR then the nurse that takes care of the paperwork telling me she is still consider full code until further signatures to be completed. It was an emergency case so I didn't have time to run and look over the chart over and over again. I had look over it a few hours prior to make sure she was still full code.

I was just confused because the doctor did sign his name and put DNR under an order. However, he wrote it in one of those receipts where you tear off form. It wasn't an actual out-of-hospital DNR order form. The last DNR flowsheet that was under advanced directives was way back in 10/19/2011 and it still listed (I want CPR done) checked with the nephew (the patient's nephew) signature. So the place where I work at didn't update the files. It was just a whole lot of stress. I barely got any sleep worrying that I might get in trouble.

She didn't code she has respiratory distress. Therefore needed treatment. It is important to know your facility policies and not depend on others.

One: Know the policies of your facility and the laws of your state. The policies and laws of random people on the internet don't matter.

Two: Everyone needs to make sure important paperwork like this gets filled out completely ASAP and completely and accurately. Otherwise, patient's wishes will be ignored for lack of a signature.

In this case, 911 and hospitalization may be in order, but if the patient codes once there, and wanted to be a DNR, and the hospital doesn't get a DNR prior to the code, the patient will be coded against his wishes.

While I think most paperwork is merely for covering our collective butts and falls to the bottom of my to-do list, anything relating to code status needs to be taken care of asap and completely.

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