Code Blue Form

Code Blue Form

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Use this form along with 'Code Blue System' 

Type of event           Actual Event            Mock Drill       Date ___________

Patient Details: Name: __________________________________ UID ______________________ Age ____________ Gender ________ Ward / Unit _________________________ Diagnosis (Pre-arrest) ________________________________________________ Any Pre-arrest intervention  ____________________________________________

Code Activation: Code activated by _____________________________ Designation__________ Time of code activation ______________ Condition at the time of code activation: Unresponsive Apnoea No Pulse Gasping Other __________________________________________________________ Time of code team arrival: 1st member __________ 2nd member ____________ Name of code blue team leader_______________ arrival time ______________

Resuscitation measures Duration for which CPR given __________________ Intubation given? Yes/No,        If Yes, then time _______ Central line given? Yes/No,      If Yes, then time _______ Defibrillator used? Yes/No,       If Yes, then time and duration ___________ List of medicine administered: S.No. Medication Dose Remark Other measures:

Outcome Outcome of resuscitation:       Patient survived       Patient Expired Time at which resuscitation efforts stopped: Vitals at stopping:   HR____  BP _______ SPO2 ______Rhythm ________ Patient shifted ICU: Yes/No      If not, location of patient ________________ Post resuscitation advice:  ______________________________________ _______________________________________________________________

Code blue team members and signatures S.No. Members name Signature

Documented by Name:                                                        Date:                          Time: Signature:

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