The standard form for an EMS cardiopulmonary resuscitation directive shall include the following information concerning the person who is the subject of the EMS cardiopulmonary resuscitation directive:
- (1) The person's name, date of birth, and gender;
- (2) The person's eye and hair color;
- (3) The person's race or ethnic background;
- (4) If applicable, the name of the hospice program in which the person is enrolled;
- (5) The name, address, telephone number, and signature of the person's attending physician, physician assistant, or nurse practitioner;
- (6) The person's signature or mark, or, if applicable, the signature of a person authorized to execute an EMS cardiopulmonary resuscitation directive;
- (7) The date on which the EMS cardiopulmonary resuscitation directive was signed; and
- (8) A statement directing emergency medical service personnel to withhold cardiopulmonary resuscitation attempts.
Source: 32 SDR 38, effective September 5, 2005.
General Authority: SDCL 34-12F-3.
Law Implemented: SDCL 34-12F-3.