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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