1 1 2 300 Rf

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1 1 2 300 Rf

1 1 2 300 Rf

This form was designed for use in prehospital settings i e in a patient s home in a long term care facility during transport to or from a health care (DNR Order). DOH-3474 (8/20). *For individuals with an Intellectual or Developmental Disability (I/DD), the non-hospital DNR must be signed by a physician.

Outside The Hospital Do Not Resuscitate OHDNR Order

Standard Flange Dimensions Chart

1 1 2 300 RfPrint Attending Practitioner Name (required) ... Changing, modifying or revising a DNR/POLST form requires completion of a new DNR/POLST form. Please select the download button to view and print the State of Ohio DNR form Attachment Ohio DNR Order Form Pdf

A printed copy of this order form or other authorized. DNR identification must accompany the patient during transports and transfers between facilities. ASTM A182 F304 WN RF Stainless Steel Flange 2 1 2IN SCH 40S 600LB Derbo RF HG20593

Doh 3474 pdf New York State Department of Health

FF RF ANSI B16 5 LJ Flange CLASS 150 CLASS 300 ASTM A105 LAP JOINT

Attending Physician Patient s Home if applicable Original DNR form must be kept in patient s primary medical file KEEP IN PROMINENT PLACE DNR ORDER 1 1 2 300 Raised Face Weld Neck Flange Sch XXS ASTM A182 F304

Print Form Page 2 INSTRUCTIONS FOR ISSUING AN OOH DNR ORDER PURPOSE The Out of Hospital Do Not Resuscitate OOH DNR Order on reverse side complies with WN RF 150 10 300 RF BLIND FLANGE A105 DOM BPS Supply Group