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DNR order ___Yes Date ___No ___Yes Date ___No Advance Directive / Living Will REVIEW OF EMERGENCY MEDICAL CARE: Was death related to a medical emergency ___Yes ___No Response to medical emergency notification timely ___Yes ___No ___NA Physician ___Yes ___No ___NA Physician Assistant ___Yes ___No ___NA Nurse Practitioner ___Yes ___No ___NA Nurse(s) ___Yes ___No ___NA Emergency Medical Techs ___Yes ___No ___NA Others ___Yes CPR ___Yes ___No ___NA ACLS List protocol (s) used (if appropriate) By EMS. ___Yes ___No ___NA Problems encountered during medical emergency, e.g., equipment, communications, transportation. Describe briefly: ___Yes ___No ___NA Providers responding maintain current certification / credentials in BCLS, ACLS (if required) ___Yes ___No ___NA SUMMARY REVIEW: [redacted] [redacted] PDF Prescribed by P6013 DOJ-OGR-00027343