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CPR Analysis Form

The document is a CPR Analysis Form used to evaluate the performance of CPR during a medical emergency. It includes sections for recording patient information, diagnosis, CPR details, and a checklist to assess the adherence to guidelines and availability of equipment. Additionally, it allows for comments on concerns, corrective actions, and follow-up recommendations post-event.

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Debamalya Deb
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380 views2 pages

CPR Analysis Form

The document is a CPR Analysis Form used to evaluate the performance of CPR during a medical emergency. It includes sections for recording patient information, diagnosis, CPR details, and a checklist to assess the adherence to guidelines and availability of equipment. Additionally, it allows for comments on concerns, corrective actions, and follow-up recommendations post-event.

Uploaded by

Debamalya Deb
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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Patient's Name:

Age / Sex:

MR No.: IP No.
Consultants Name:
CPR ANALYSIS FORM

Diagnosis: __________________________________ Location: ___________

Code Announced: Yes / No, If yes announced by ______________________ Time: _______

CPR started by: _________________________________ Time: ______________

CPR stopped on advise of: _______________________ Time: ______________

DESCRIPTION YES NO If No, please explain

All members responded timely?

BLS properly performed?

ACLS guidelines followed?

Defibrillator properly connected,


turned on?

All required equipment available


and operational?

All ACLS drugs available?

Definitive airway secured and


verified within 5 minutes?

Proper technique of
defibrillation?

Operator verified “all clear”


prior to defibrillation?

Initial rhythm strip obtained?

Family notified and counseled?

CPR Sequence of events


recorded

Did patient survive? Yes No

TXH/QAD/F 03 Version 2.0 Page 1 of 2


Patient's Name:

Age / Sex:

MR No.: IP No.
Consultants Name:

List of Problems or Concerns: (Comments & Gaps)

Post Event (CPR) Evaluation: (Corrective Action and follow up recommendations)

Corrective actions recommendations:

Follow up instructions:

Name & Signature of Team Leader: _____________________________

Verified by Code blue Team Chairperson : ______________________________

Corrective actions recommended is adequate: Yes No

TXH/QAD/F 03 Version 2.0 Page 2 of 2

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