Code Blue Running Sheet
ID Label
Patient Name:...................................................................................... UHID No.:................................................
Date:............................Time of Recognition of event ........................... Location ................................................
Was a Hospital-wide resuscitation response activated? Yes No
Witnessed: Yes No Indicate all monitors that were present at onset: ECG / Pulse Oxymetry / BP
Patient conscious at onset: Yes No
Airway / Ventilation Circulation
At Onset: Spontaneous Apnea Assisted First Document Rhythm..............................................
Time of First Assisted Ventilation................................ Time Chest Compressions were started.....................
ETT Intubation Time........................ Size....................
Patient Defibrillated Yes No
By Whom.....................................................................
If Yes: Time of First shock..........................................
.....................................................................................
Bolus Dose Infusions Doses / cc per hr
Comments:
Lidocaine Dose
Atropine Dose
Amiodaronce
Defil/Cardiov
i.e. Peripheral
Dobutamine
Epinephrine
Sodabicarb
Dopamine
Rhythm
Central Line
Joules
Dose
Dose
Dose
Time Resp. Pulse BP Placement, IO Chest
tube, Vital signs,
Response to
interventions
0
min.
05
min.
10
min.
15
min.
20
min.
25
min.
30
min.
35
min.
40
min.
45
min.
50
min.
Outcome
Resuscitation: Event ended at............................. Status Alive Dead
Reason Resuscitation ended: Return of Circulation (> 20 min) Efforts Termininates
Medical Futility Advance Directives Restrictions by Family
Indicate Specific Problems encountered in each of the following categories
Airway: Delay Multiple attempts Aspiration Misplacement / Displacement
No issues
Vascular Access: Delay Infiltration / Displacement No issues
Chest Compressions: Delay Indequate force Rib Fractures
No issues
Defibrillation: Equipment not available Mulfunction No issues
Medications: Not available Nurse not aware of location No issues
Leadership: Delay in identifying leader Chaos No issues
Equipment: Not available Did not function Delay in availability No issues
Staff Record attending Code Blue Call
Name Title Time Arrived
1. .............................................. ................................................ ..................................................
2. .............................................. ................................................ ..................................................
3. .............................................. ................................................ ..................................................
4. .............................................. ................................................ ..................................................
5. .............................................. ................................................ ..................................................
6. .............................................. ................................................ ..................................................
Doctor ........................................... Nurse ........................................
Sign. & Stamp Sign. & Stamp
