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Code Blue Form for Resuscitation

This document is a code blue form used to record information during a medical emergency resuscitation effort. It includes sections to document the patient information, the condition found, resuscitation efforts such as CPR and intubation, drugs and fluids administered, interventions, outcomes, and signatures of the medical staff involved. The form is designed to comprehensively capture all critical details of an attempted resuscitation in a standardized format for the patient's medical record.

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Prio Si Iyo
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738 views1 page

Code Blue Form for Resuscitation

This document is a code blue form used to record information during a medical emergency resuscitation effort. It includes sections to document the patient information, the condition found, resuscitation efforts such as CPR and intubation, drugs and fluids administered, interventions, outcomes, and signatures of the medical staff involved. The form is designed to comprehensively capture all critical details of an attempted resuscitation in a standardized format for the patient's medical record.

Uploaded by

Prio Si Iyo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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CODE BLUE FORM

PATIENT IDENTIFICATION
STARTOF CODE
DATE: TIME: (Military Time) FOUND BY: LOCATION:

CONDITION: FOR INTUBATION


ONLY APNEIC PULSELESS OTHER: __________________________

RESUSCITATION EFFORTS
CPR Initiated Military TIME MD IN CHARGE:

Intubation Military TIME

Central Line Placement Military TIME

Other Military TIME ( Describe ) > >

DRUGS
DRUGS / FLUID / RATE TIME / DOSE TIME / DOSE TIME / DOSE TIME / DOSE TIME / DOSE TIME / DOSE
Epinephrine Bolus Syr.
Atropine Bolus Syr.
Lidocaine Bolus Syr.
Sodium Bicarbonate Bolus Syr.
Vasopressin Bolus ( Vial 20 units )
Magnesium Sulfate Bolus
Amiodarone Bolus 50mg / ml - 3 ml
Dopamine Drip
Levophed Drip
Neosynephrine Drip

I.V. / FLUID / RATE TIME / RATE TIME / RATE TIME / RATE TIME / RATE TIME / RATE TIME / RATE
I.V. Fluid

INTERVENTIONS TIME TIME TIME TIME TIME TIME


Rhythm / HR
BP
Defib Time / Joules
Pacer / Time / MA
Labs / ABGs Sent
RESUSCITATION OUTCOME
RECOVERY TIME HR: _________ RR: _________ RHYTHM: _________
STOPPED: ____________ BP: _________
RECEIVING UNIT:

DEATH TIME OF DEATH: _________________ PMD NOTIFIED BY: ________________________________________

MD SIGNATURE: RN SIGNATURE / TITLE:

WHITE COPY = Chart YELLOW COPY = ICU Medical Director PINK COPY = Pharmacy

PART OF THE MEDICAL RECORD


8850447 Rev. 05/05 Code Blue Form_NURSING PAGE 1 of 1

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