Code blue recording sheet
Patient name: ……………………………………………….. MRN:……………………… Age:……………………
Consultant: ……………………………………………………… unite: …………………………………………….
Diagnosis: …………………………………………………………………………………………………………………………………
A Date: / / B Type of arrest:
Time of activation code: : respiratory
CPR starting time: : cardiac
C Respiratory aid: D Type of rhythm:
Bag-valve mask Pulseless VT
ETT Size: VF
Inserted by:…………………………………… Asystole
PEA
Resuscitation Procedures:
Time Vital signs Given Drugs Defibrillation
Pulse BP RR Rhythm
:
:
:
:
:
:
:
:
:
:
:
:
:
:
Nursing supervisor Name/ID: …………………………… Team leader Name/ ID: ……………………………….
Nursing supervisor Signature: ………………………… Team leader Signature: ……………………………….
Attending team:
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Code Blue Team Names Arrival time
Team leader :
Anesthetist :
Nursing supervisor :
Concerned specialty registrar :
Critical care unite Nurse :
ER / floor / unite Charge nurse :
Nursing supervisor notes:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Team leader comments:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
CPR outcome:
Successful
Unsuccessful
Transferred to : ………………
Follow up :
______________________________________________________________________________________
______________________________________________________________________________________
Nursing supervisor Name/ID: …………………………… Team leader Name/ ID: ……………………………….
Nursing supervisor Signature: ………………………… Team leader Signature: ……………………………….
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Code blue evolution
To be completed immediately after code blue. This form is not part of the medical record. Deliver to
performance improvement director after completion.
Part 1:
To be completed by nursing supervisor:
Yes No Comments
Was Code Blue paged appropriately
Time elapsed after page for arrival of code team < 3
minutes?
Was CPRin progress before arrival of code team ?
Did nurses prepare medication in accordance with ACLS
standards without specific directions from physician ?
Was needed equipment available and ready for use?
Name / ID / Stamp: ______________________________________ Data: ________________________
Part 2 :
To be completed by physician:
Yes No Comments
Was code performance of personnel appropriate?
Were there difficulties with availability/performance of
equipment?
Were all needed drugs available?
Is there opportunity for improvement in resuscitation
management of this case?
Explain by listing deficiencies?
Name / ID / Stamp: ______________________________________ Data: ________________________
Part 3:
To be completed by PI Director:
Action plan for resolution of any deficiencies :
Name / ID / Stamp: ______________________________________ Data: ________________________
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