A physician, nurse practitioner or physician assistant uses this one-page New York order, revised 8/20, to direct that a person outside the hospital not be resuscitated. With a nonhospital DNR, EMS will not begin CPR, including chest compressions, electric shock, intubation or heart-restarting medication. It covers DNR only; the MOLST is the only form that also documents a nonhospital do-not-intubate order.
The physician, nurse practitioner or physician assistant fills in the person's name and date of birth and signs with printed name, license number and date. For a person with an intellectual or developmental disability, a physician must sign.
Download the current version from the source each time; forms change without notice.
Nonhospital Order Not to Resuscitate (DNR Order)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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A physician, nurse practitioner or physician assistant can sign DOH-3474, adding a license number. For individuals with an intellectual or developmental disability, the nonhospital DNR must be signed by a physician, who must follow SCPA Section 1750-b when the person lacks capacity and has no health care proxy.
No. The practitioner should review it at least every 90 days and note the review in the medical chart, but a new form is not required. The order remains valid and must be followed, even if a review was missed, unless it is known to have been revoked.
DOH-3474 documents a nonhospital DNR only. The MOLST (DOH-5003) is the only authorized New York form for documenting both nonhospital DNR and DNI orders and can carry other life-sustaining treatment orders; it is intended for patients with serious health conditions, those in long-term care, or those who might die within a year.