Virginia Administrative Code › Title 12 - HEALTH › Agency 5 - DEPARTMENT OF HEALTH › Chapter 66 - REGULATIONS GOVERNING DURABLE DO NOT RESUSCITATE ORDERS › Part III - Requirements and Provisions › Section 12VAC5-66-40 - The Durable Do Not Resuscitate Order Form

Current through Register Vol. 40, No. 24, July 15, 2024
The Durable DNR Order Form shall be a standardized document
					 as approved by the board and consistent with these regulations. The following
					 requirements and provisions shall apply to the approved Durable DNR Order
					 Form.
1. Content of the Form - A
				  Durable DNR Order Form shall contain, from a physician with whom the patient
				  has a bona fide physician/patient relationship, a do not resuscitate
				  determination, signature and the date of issue, the signature of the patient
				  or, if applicable, the person authorized to consent on the patient's
				  behalf.
2. Effective Period for a
				  Signed Durable DNR Order - A signed Durable DNR Order shall remain valid until
				  revoked in accordance with § 54.1-2987.1 of the Code of Virginia and
				  12VAC5-66-80 E or until rescinded,
				  in accordance with accepted medical practice, by the provider who issued the
				  Durable Do Not Resuscitate Order.
3. Durable DNR Order Form - A Durable DNR
				  Order or Alternate Durable DNR jewelry that complies with
				  12VAC5-66-50 shall be valid for
				  the purposes of withholding or withdrawing cardiopulmonary resuscitation by
				  qualified health care personnel in the event of cardiac or respiratory
				  arrest.
4. Availability of the
				  Durable DNR Order Form. The Durable DNR Order Form that complies with this
				  section or Alternate Durable DNR jewelry that complies with
				  12VAC5-66-50 shall be maintained
				  and readily available to qualified health care personnel at the patient's
				  current location or residence.
5.
				  Qualified health care personnel may honor a legible photocopy of a Durable DNR
				  Form or Other Durable DNR Order as if it were an original.
6. A patient who is traveling outside his
				  home or between health care facilities should have an original or photocopied
				  Durable DNR Order, Other Durable DNR Order, or Alternate Durable DNR jewelry
				  accompany him.
7. Distribution of
				  Durable DNR Order Forms - The authorized Virginia Durable DNR Order Form shall
				  be a standardized form available for download via the Internet from the Office
				  of Emergency Medical Services website. The downloadable form will contain
				  directions for completing the form and three identical Durable DNR Order Forms:
				  one original form to be kept by the patient, the second to be placed in the
				  patient's permanent medical record, and the third to be used by the patient for
				  requesting Alternate Durable DNR jewelry.
8. Hard copies of the Durable DNR Order Form
				  shall also be made available to physicians or licensed health care facilities
				  by the Office of EMS. The Office of EMS may utilize a vendor to print and
				  distribute the Durable DNR Order Form and a nominal fee may be charged in an
				  amount necessary to cover printing and shipping fees.
Statutory Authority
§§ 32.1-12 and 32.1-111.4 of the Code of
						Virginia.