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Form Code Blue

This document is a code blue form used to record information during a resuscitation effort. It includes fields to document the patient identification, date and time the code was called, condition found, location, efforts performed, drugs and fluids administered, interventions, recovery information, and outcome. The form is signed by the attending MD and nurse and made part of the patient's medical record.

Uploaded by

Hendra Kurniawan
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
1K views1 page

Form Code Blue

This document is a code blue form used to record information during a resuscitation effort. It includes fields to document the patient identification, date and time the code was called, condition found, location, efforts performed, drugs and fluids administered, interventions, recovery information, and outcome. The form is signed by the attending MD and nurse and made part of the patient's medical record.

Uploaded by

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

PATIENT IDENTIFICATION

START
DATE:

TIME:

CONDITION:

OF

CODE

(Military Time) FOUND BY:

FOR INTUBATION
ONLY

LOCATION:

APNEIC

PULSELESS

RESUSCITATION

OTHER: __________________________

EFFORTS

MD IN CHARGE:

CPR Initiated

Military TIME

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
RECOVERY

TIME
STOPPED: ____________

BP: _________

OUTCOME

HR: _________

RR: _________

RHYTHM: _________

RECEIVING UNIT:

DEATH

TIME OF DEATH: _________________

MD SIGNATURE:

PMD NOTIFIED BY: ________________________________________


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

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