DHEC Form 3462 "Do Not Resuscitate Order" - South Carolina

What Is DHEC Form 3462?

This is a legal form that was released by the South Carolina Department of Health and Environmental Control - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the South Carolina Department of Health and Environmental Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DHEC Form 3462 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Health and Environmental Control.

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Download DHEC Form 3462 "Do Not Resuscitate Order" - South Carolina

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Emergency Medical Services
Do Not Resuscitate Order
SOUTH CAROLINA
EMERGENCY MEDICAL SERVICES
RESUSCITATE
DO NOT RESUSCITATE ORDER
NOTICE TO EMS PERSONNEL
This notice is to inform all emergency medical personnel who may be called to render assistance to
that he/she has a terminal condition which has been diagnosed by me and is at
(Name of Patient)
least eighteen (18) years of age, and has specifically requested that no resuscitative efforts including artificial stimulation
of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary
arrest.
REVOCATION PROCEDURE
THIS FORM MAY BE REVOKED BY AN ORAL STATEMENT BY THE PATIENT TO EMS PERSONNEL, OR BY
MUTILATING, OBLITERATING, OR DESTROYING THE DOCUMENT IN ANY MANNER.
Date
Patient's Signature (or Surrogate or Agent)
Physician's/ APRN's/ PA's Name (Please Print)
Physician's/ APRN's/ PA's Signature
Physician's/ APRN's/ PA's Address
Physician's/ APRN's/ PA's Telephone Number
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 3462 (01/2020)
Emergency Medical Services
Do Not Resuscitate Order
SOUTH CAROLINA
EMERGENCY MEDICAL SERVICES
RESUSCITATE
DO NOT RESUSCITATE ORDER
NOTICE TO EMS PERSONNEL
This notice is to inform all emergency medical personnel who may be called to render assistance to
that he/she has a terminal condition which has been diagnosed by me and is at
(Name of Patient)
least eighteen (18) years of age, and has specifically requested that no resuscitative efforts including artificial stimulation
of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary
arrest.
REVOCATION PROCEDURE
THIS FORM MAY BE REVOKED BY AN ORAL STATEMENT BY THE PATIENT TO EMS PERSONNEL, OR BY
MUTILATING, OBLITERATING, OR DESTROYING THE DOCUMENT IN ANY MANNER.
Date
Patient's Signature (or Surrogate or Agent)
Physician's/ APRN's/ PA's Name (Please Print)
Physician's/ APRN's/ PA's Signature
Physician's/ APRN's/ PA's Address
Physician's/ APRN's/ PA's Telephone Number
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 3462 (01/2020)
DNR INFORMATION FOR THE PATIENT, THE PATIENT'S FAMILY,
PHYSICIAN, ADVANCED PRACTICE REGISTERED NURSE (APRN),
PHYSICIAN ASSISTANT (PA), AND EMS PERSONNEL
1.
Responsibilities of the Patient or his/her Surrogate or Agent
The patient and his/her surrogate or agent:
Will make all care givers aware of the location of the EMS DNR Form and will ensure that the form is
displayed in such a manner that it will be visible and available to EMS personnel;
Understanding the consequences of refusing resuscitative measures;
Are aware that if the form is altered in any manner resuscitative measures will be initiated; and
Understand that in all cases, supportive care will be provided to the patient.
2.
Responsibilities of the Health Physician
The patient's physician, APRN, or PA:
Has determined that the patient has a terminal condition;
Has completed the patient's EMS DNR Form;
Has explained to the patient and family the consequences of withholding resuscitative care; the
medical procedures that will be withheld and the palliative and supportive care that will be
administrated to the patient; and
Must execute the DNR order pursuant to the provisions of the Emergency Medical Services Do Not
Resuscitate Order Act in accordance with their respective practice acts.
3.
Responsibilities of EMS Personnel
EMS personnel:
Will confirm the presence of the EMS DNR Form and the identity of the Patient;
Upon finding an unaltered EMS DNR Form, will withhold or withdraw resuscitative measures such as
CPR, endotracheal intubation or other advanced airway management, artificial ventilation,
defibrillation, cardiac resuscitation medication and related procedures;
Will provide palliative and supportive treatment such as suctioning the airway, administration of
oxygen, control bleeding, provision of pain and non-cardiac medications, provide comfort care and
provide emotional support for the patient and the patient's family; and
Will assure that the DNR Form accompanies the patient during transport.
DHEC-3462 (01/2020)
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