Scribd
Upload
19 views

CPR FORM

This document is a cardiac arrest resuscitation form that captures essential patient information, resuscitation details, and vital parameters during a code blue event. It includes sections for documenting the patient's medical history, resuscitation flow record, and the outcome of the resuscitation efforts. The form is intended for use with every patient undergoing CPR, with original records kept in patient files and copies submitted to nursing staff.

Uploaded by

quality.yhk
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
19 views

CPR FORM

This document is a cardiac arrest resuscitation form that captures essential patient information, resuscitation details, and vital parameters during a code blue event. It includes sections for documenting the patient's medical history, resuscitation flow record, and the outcome of the resuscitation efforts. The form is intended for use with every patient undergoing CPR, with original records kept in patient files and copies submitted to nursing staff.

Uploaded by

quality.yhk
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

Patient’s Name:_______________________________________________________________________

UHID: __________________________IPID_______________ Age: _______Sex: ________________


DOA & Time: __________________________ MLC/Non- MLC: _________________________
Diagnosis: ___________________________________________________________________________
Consultant Name ________________________________________
Admitted in: Ward_____________ Any other area____________

CARDIAC ARREST RESUSCITATION FORM

Brief summary of the case:

K/C/O: DM/ HTN/ CHD/ Br. Asthma/ COPD/ CRF/ Hepatic Failure/ CVA/ Allergic reaction/ Septicemia
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

Resuscitation Flow Record (To be filled by the doctor):

Date and Time of code blue:____________________________ Location: ________________________________


Identified By: ______________________________ Time____________________
Code Blue Announced by: ___________________________________Time_______________________
Resuscitation Started At _____________________ Was the patient received in a collapsed state: Yes/No
Level of consciousness prior to cardiac arrest:________________________________________
Airway/Ventilation Circulation
At onset: Spontaneous/ Apnea/ Assisted First documented rhythm:_______________________
Time of first assisted ventilation: ________________ Time of starting chest compressions:_______________
ETT intubation Time: _________Size:____________ Defibrillator used: Yes/No
By whom: _________________________ If yes, time of First Shock:______________________
IV Cannula Yes No Time: Size: By:
C.V. Catheter Yes No Time: Size: By:

Vital parameters Drugs (Infusion/rate/dose) Defibrillation


Time
Pulse Rhythm Resp. B.P. Epinephrine Atropine Lidocaine Amiodarone Any other drug Pre rhythm Post rhythm

0 min
2 min
4 min
6 min
8 min
10 min
12 min
14 min
16 min
18 min
20 min
22 min
24 min
26 min
28 min
30 min

Resuscitation: Event ended at: _______________ Status: Alive/ Dead If alive, shifted to: Ward/ OT
Reason of ending the resuscitation: Return of Spontaneous Circulation (ROSC)/ Medical Futility/ Advance directives/ Restrictions by family
If dead, declared dead at _________________________
By Dr. ______________________________________
Signature with name of the doctor

(To be used for every patient undergoing CPR, original to be kept in the patient record & copy to be submitted to the Nursing Incharge)

You might also like