W. Va. Code § 16-30C-6
(f) For persons not present or residing in a health care facility, the do-not-resuscitate order shall be noted on a physician, physician’s assistant, or advanced practice registered nurse orders for scope of treatment form or in the following form on a card suitable for carrying on the person:
Do-Not-Resuscitate Order
“As treating physician, physician’s assistant, or advanced practice registered nurse of ____________________________ and a licensed physician, physician’s assistant, or advanced practice registered nurse, I order that this person SHALL NOT BE RESUSCITATED in the event of cardiac or respiratory arrest. This order has been discussed with ___________________________________ or his/her representative ____________________________________ or his/her surrogate decisionmaker ____________________________ who has given consent as evidenced by his/her signature below.
Provider Name
_________________________________________________
Provider Signature __________________________________________________
Address ______________________________________________________________
Person Signature ________________________________________________________
Address _______________________________________________________________
Surrogate Decision Maker Signature _________________________________________
Address ______________________________________________________________”.
(g) For persons residing in a health care facility, the do-not-resuscitate order shall be reflected in at least one of the following forms: