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    ARMC-RAC-MSP - Code Blue Attachment 7.1

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    ianecunar
    This document is a record of a code blue event at a hospital. It contains fields to record patient details like age, medical history, allergies and medications. It also contains a timeline of interventions during the code like heart rhythm, defibrillation attempts, medications administered and vital signs. The outcome was that the patient was either revived or died. The document aims to capture all the key details of resuscitation efforts during a cardiac or respiratory arrest event.

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    ARMC-RAC-MSP - Code Blue Attachment 7.1

    Uploaded by

    ianecunar
    6 views1 page
    This document is a record of a code blue event at a hospital. It contains fields to record patient details like age, medical history, allergies and medications. It also contains a timeline of interventions during the code like heart rhythm, defibrillation attempts, medications administered and vital signs. The outcome was that the patient was either revived or died. The document aims to capture all the key details of resuscitation efforts during a cardiac or respiratory arrest event.

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    ARMC-RAC-MSP- Code Blue Attachment 7.1

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    This document is a record of a code blue event at a hospital. It contains fields to record patient details like age, medical history, allergies and medications. It also contains a timeline of interventions during the code like heart rhythm, defibrillation attempts, medications administered and vital signs. The outcome was that the patient was either revived or died. The document aims to capture all the key details of resuscitation efforts during a cardiac or respiratory arrest event.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    6 views1 page

    ARMC-RAC-MSP - Code Blue Attachment 7.1

    Uploaded by

    ianecunar
    This document is a record of a code blue event at a hospital. It contains fields to record patient details like age, medical history, allergies and medications. It also contains a timeline of interventions during the code like heart rhythm, defibrillation attempts, medications administered and vital signs. The outcome was that the patient was either revived or died. The document aims to capture all the key details of resuscitation efforts during a cardiac or respiratory arrest event.

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    © All Rights Reserved
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    of 1

    CODE BLUE RECORD

    DATE: CODE START TIME: CODE BLUE TEAM ARRIVAL TIME:


    Check if : ⃝ ADULT ⃝ PEDIA
    ⃝ Pre-ARMC-RAC, CPR duration in minutes: ⃝ NA Arrest: ⃝ Witnessed ⃝ Un-witnessed

    ⃝ In-ARMC-RAC cardiorespiratory arrest Brought in by: ⃝ Relatives ⃝ Ambulance ⃝ Red Crescent ⃝ NA ⃝ others:_______________

    ALLERGIES: ⃝ No Known Allergy

    MEDICAL HISTORY: ⃝ None


    ⃝ No informant
    RECENT MEDICATIONS:
    ⃝ None
    ARTIFICIAL AIRWAY Type Size Attempted by Result, check: Secured at level: VASCULAR ACCESS Site Size Type
    INSERTION ATTEMPTS: INSERTION ATTEMPTS:
    ⃝ 1st/time: ⃝S ⃝F _____cm ⃝NA ACCESS 1, time: ⃝ IV ⃝ IO ⃝ CVC
    ⃝ 2nd/time: ⃝S ⃝F _____cm ⃝NA ACCESS 2, time: ⃝ IV ⃝ IO ⃝ CVC

    ⃝ 3rd/time: ⃝S ⃝F _____cm ⃝NA ACCESS 3, time: ⃝ IV ⃝ IO ⃝ CVC

    ⃝ Others: ⃝S ⃝F _____cm ⃝NA BASELINE RBS mg/dL:

    MEDICATIONS, check if: ⃝ Adult dose ⃝ Age/Weight-adjusted Pediatric dose Other Stat Meds & ABG’s &
    TIME HEART RHYTHM DEFIBRILLATION
    (Every 2 min-
    (specify) EPINEPHRINE AMIODARONE NAHCO3- 8.4% DEXTROSE 50% I.V./ I.O. FLUIDS STAT
    check)
    Joules Response Dose # Time Dose (mg) Time Vol (mL) Time RBS/ time Vol (mL) Name/Dose Time LABS/ Time
    ⃝1

    ⃝2

    ⃝3

    ⃝4

    ⃝5

    ⃝6

    ⃝7

    ⃝8

    ⃝9

    ⃝10

    ⃝11

    ⃝12

    R.O.S.C. VITAL SIGNS  BP: RR: Temp: O2 Saturation:


    (Return of Spontaneous Circulation)
    ⃝ NA, patient has EXPIRED

    TIME CODE ENDED: ………………………………………………… DATE: …………………………………………… OUTCOME: ⃝ Revived ⃝ Died, pronounced by: DR. ………………………………………………………………
    TOTAL DURATION: ………………………………………………………………………………...……………minutes TIME OF DEATH: …………………………………………………………………… DATE: …………………………………………………………… ⃝ NA
    ACLS Function Name Signature ACLS Function Name Signature
    Team Leader RN 1 Primary Nurse / CPR
    & Ventilation
    General Physician / ER Dr RN 2 Medication Nurse
    Airway Roles
    Emergency Medical RN 3 Head Nurse or
    Services Personnel / Shift in-Charge / Recorder

    Duty Manager -

    Debriefing done by:

    Debriefing done at/on:

    ARMC-RAC-CBR S-successful insertion F-failed insertion IV-Intravenous IO-Intraosseous CVC- Central Venous Catheter NAHCO3- Sodium Bicarbonate O2- oxygen VS-Vital Signs

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