MC 3834 (10/95)--front Vanderbilt University Medical Center CODE STATUS PROGRESS NOTE (Insert in sequence in Progress Note section) BOTH SIDES OF THIS FORM MUST BE COMPLETED IN FULL, INCLUDING LEGIBLE SIGNATURES, WITH EACH CHANGE IN A - mc-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the appropriate code status for the patient: DO NOT RESUSCITATE, DO NOT INTUBATE, or LIMITED CARDIOPULMONARY RESUSCITATION. Ensure you check all relevant options regarding withholding specific treatments.
3. Fill in the DIAGNOSIS and PROGNOSIS/BASIS FOR PROGNOSIS sections with clear and concise information about the patient's condition.
4. Indicate the patient’s decision-making capacity and provide reasons if it is absent or variable.
5. Check all applicable reasons for the DNR/DNI/LCPR order, ensuring to specify any advance directives or requests from patients or surrogates.
6. Document discussions that have occurred regarding code status with family, nursing staff, house staff, and consulting physicians.
7. Complete the section on who performed the discussion of code status and note any parties with whom discussions have not taken place.
8. Outline treatment goals clearly, specifying orders as necessary for comfort care or other therapies.
9. Conclude with a summary statement or additional comments before signing and dating the form at the bottom.

Utilize our platform to streamline your document editing and signing process for free!