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Code Blue Evaluation Form

The document is a code blue review form evaluating the response to and outcome of a code blue event. It summarizes whether the rapid response team was notified, if appropriate personnel responded, if guidelines were followed, and the patient outcome. Any complications or needed improvements are noted. The form is to be attached to the original code record and sent to the performance improvement department for review rather than medical records.

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Jessica Garlets
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1K views1 page

Code Blue Evaluation Form

The document is a code blue review form evaluating the response to and outcome of a code blue event. It summarizes whether the rapid response team was notified, if appropriate personnel responded, if guidelines were followed, and the patient outcome. Any complications or needed improvements are noted. The form is to be attached to the original code record and sent to the performance improvement department for review rather than medical records.

Uploaded by

Jessica Garlets
Copyright
© Attribution Non-Commercial (BY-NC)
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 Review/Evaluation Name: ______________________ Time: __________ MR#: _______________ Date of Event: _______________ Inpatient Outpatient

Location: _________________

Was the RAT Team notified before the patient coded? Date RAT Team notified: _________________________ Patient Outcome: Comments: No Change

Yes

No

Time: ___________________

Pt transferred to higher level of care Tele ICU

The appropriate personnel responded to the code Primary Nurse @ Bedside There was one designated physician leader Crash Cart immediately available -Equipment functioned properly -Medication immediately available ACLS Guidelines followed? IV present or established timely? Airway established? Initial rhythm identified & documented? Yes Yes Yes Yes No No No No

Yes Yes Yes Yes Yes Yes

No No No No No No No No No

AED applied properly? Yes All clear call before each shock? Yes Complications of resuscitation? Yes

Comments & Improvements: (All No comments must be explained)

Patient Outcome:

Expired

Survived

Transferred to: __________________ Date: _______________________

Reviewer: ______________________________________

Please attach this form to a copy of the original ARMC Cardiopulmonary Resuscitation Form & send to PI Dept DO NOT SEND TO MEDICAL RECORDS

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